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-J 6youa r r <br /> r <br /> STATE OF CALIFORNIA + <br /> o <br /> STATE WATER RESOURCES CONTROL BOARD w,ate o P <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A gw I.;} a <br /> COMPLETE THIS FORM FOR EACH CILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY SED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> -0 <br /> ADDRESS NEAREST CROSS STREET PARC EL III(OPTXINAL) <br /> a2 / / v f <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TOIN BOX O CORPORATION INDIVIDUAL 0 PARTNERSHIP I�LOCAL-AGENCY <br /> OCAL-DISTRIG CY Q COUNTY-AGENCY STATE AGENCY O FEDERAL-AGENCY <br /> TS <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR RE/ IF IND IANON #OF TANKS AT SITE E.P.A. I.D.#1CPHmal) <br /> 3 FARM Q 4 PROCESSOR 6 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 /> I PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> A/` e Q S Z <br /> MAILING OR STREET ADDRESS bmbWIua� INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP =COUNTY-AGENCY E�] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANKOWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SIA MC aJ ,,� <br /> MAILING OR STREET ADDRESS ✓ babindcals ED INDIVIDUAL LOCAL-AGENCY O STATE AGENCY <br /> Q CORPORATION = PARTNERSHIP 0 COUNIY-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 4 4 D 3 <br /> V. PETROLEUM UST FINANCI SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm bintlkm I SELF-INSURED =2 GUARANTEE [_1 ]INSURANCE 0 A SURETYBCND <br /> D 5 LETTEROFCREDT 6 EXEMPTION Q 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. III.O <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# JURISDICTION# FACILITY# <br /> `IJ = S 7 <br /> LOCATION CODE OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o/ sdF a <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 /> FORM A(5-91) FORM33A5 <br />