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' .�50Vw t. <br /> ' STATE OF CALIFORNIA `i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> �� - �o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� v; <br /> . , a <br /> •w•`wt�-ow�Y�� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM IV2 INTERIM PERMIT 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE ©Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D FACILITYNAME OF SATOR <br /> A N ST CROSS ST EES PARCELR(OPrpNAU <br /> l <br /> I N STATE ZIP Z SI PH E Jp( ACODE <br /> CA <br /> TOINDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCALAGENCY 0 COUNTY-AGENCY D STATE-AGENCY <br /> DGTRICTS D FEDERAL-AGENCY <br /> TYPE OF BUSINESS 0 1 GAS STATION F-1 2 DISTRIBUTOR 0 ✓ F INDIAN A OF TAWS AT SITE E.P.A. .D.R(OPlimal) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE R WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE R WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> VITH AREA CODE <br /> II. PROPERTY OWNER INFORM TION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETAOO HESS ✓ boxbindicM 0 INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AOENCY <br /> CORPORATION Q PARTNERSHIP 0 COUNTY AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE R 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 O'N'KaOs INDIVIDUAL 0 LOCAL-AGENCY 1] STATEAGENCY <br /> =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE t WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4 4]-I I=EFT-I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ mx miMicale I.J I SLUE INSURED = 2 GUARANTEE 0 3 INSURANCE E-I 4 SURETYBOND <br /> 0 5 IETTERCFCREDIT 0 6 EXEMPTION = W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.ly <br /> 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 S SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY k e *- <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3,q I 1Z_ 1 z o 1333 <br /> LOCATION -OPTIONAL ICENSUST C 4 -O I L SUPVISOR-DISTRICT DFO� NA <br /> L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,U LESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ` - FOR0033AR6 <br />