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eo u <br /> STATE OF CALIFORNIA P i <br /> STATE WATER RESOURCES CONTROL BOARDy�. • ; o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A yo <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION IVT PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> IIAO FACT ITY NAM NAMEOFOPERATOR <br /> ADDR7 :30 W Fr NEAREST CROSS STREET PMCEL#(OPrx)NAU <br /> CITY RAME x STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> `J��/a` CA <br /> ✓ Box <br /> TO INDICATE D CORPORATION INDIVIDUAL E-1 PARTNERSHIP LOCAL-AGENCY Q COUNTY,AGENCY O STATE-AGENCY O FEDERAL-AGENCY <br /> DSTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION F] 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS SITE E.P.A. I.D.#(optimal) <br /> 3 FARM 4 PROCESSOR � RESERVATION <br /> 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxblydkW 0 INDIVIDUAL 0LOCAL-AGENCY f�STATE-AGENCY <br /> E�]CORPORATION E] PARTNERSHIP = COUNTVAGENCY FEDENAL-AWNCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box binEkals INDIVIDUAL O LOCAL-AGENCY STATE.AGENCY <br /> CORPORATION (] PARTNERSHIP Q COUNTY-AGENCY (] FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4]- I� Z Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biNlkaW = I SELF-INSURED0 GUARANTEE [__13 INSURANCE (]A SURETYBOND <br /> 0 5 LETTER OF CREDIT 6 EXEMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O it.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY#�l JURISDICTION#� •�N FACILITY#� T�-� � 1391 <br /> LOCATIONCODDE -OPTIONAL CENSUS RACT#_OPTAONAL SUPVISOR-DISTRICT CODE-OPTIONAL I <br /> 33 8 32j <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS MANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) <br /> FORW37Ad <br /> `/ �4 <br />