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R <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 '; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D A NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED S <br /> ONE ITEM O 2 INTERIM PERMIT D 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE d <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACI ITY NAME w NAME OF OPERATOR <br /> ADDRES NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NARE STATE ODE SITE PHONE#WITH AREA CODE <br /> S CA <br /> ✓ Box <br /> TO INDICATE E-1 CORPORATIONINDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY Q CO STATE-AG D CY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O i GAS STATION 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.a Wdmal) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#T <br /> REA CODE DAYS: NAME(LAST,FIRST) PHONE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH EACODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE i <br /> II. PROPERTY OWNER INFORMATION- MUST BE CO LETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindkc INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME SIT <br /> ZIP CODE PHONE#WITH AREA CODE <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF DDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bUblaN = INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> O COflPOR ON O PARTNERSHIP COUNrY.AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE CODE PHONE#WITH AREA CODE <br /> CTY(TK) <br /> RD OF EQUALIZATION USTSTORAGE FEE AC LINT NUMBER-Call(916) 3-9555 if questions arise. <br /> HQ 4 4 ��7-IfpJ <br /> OLEUMUSTFINAN RESPONSIB -(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box binalcate ED 019akpANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT ElEEEXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will he sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD RE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.O III. <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 A S IGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Y? I I 1Q1aF(v_* <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIO AL <br /> a <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(B)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0933A5 <br /> souk" 1 z✓' /� <br />