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coo. e <br /> STATE OF CALIFORNIA `Oi <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �e <br /> ,�4�M,� <br /> COMPLETE THIS FORM FORE H FACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT Q 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME1 NAME OF OPERATOR <br /> kIo M N �ne,✓1 <br /> ADDRESS NEAREST CROSS STREET PARCEL IOPrIGNAQ <br /> E czu S <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> � ca 9S�S— <br /> ✓ BOX <br /> TO INDICATE IQ CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION IQ 2 DISTRIBUTOR Q '/ERVATION <br /> IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(opNmap <br /> 0 3 FARM 4 PROCESSOR O S OTRES <br /> HER 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 /> PHONE V"THARPICO <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME , CARE OF ADDRESS INFORMATION <br /> MAILIN OR STREET ADDRESS ✓boxbiMicab Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> SOOa r, CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S— <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bintlicau Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <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 4 4 - 22 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box blWicaN IQ 1 SELF-INSUREDQ 2 GUARANTEE Q 3 INSURANCE Q A SURETY BOND <br /> Q5 LETTEROFCREDT a EXEMPTION Q N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.vIII. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrTY# <br /> osm-zi <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 323 G <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) �3A 5 <br />