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STATE OF CALIFORNIA r t' <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> A COMPLETE THIS FORM FOR EACH FACILITYISITE c•�ff <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY 517E CLOSURE <br /> I. FACILITY/SITE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) <br /> DSAOR 1 NAME l NAME OF OPERATOR <br /> ADDRESS NEARE T ROSS FEET d^^ J PARCEL IOPfgNAW <br /> CIN !s gTA ZIP SITE PHONE WITH AREA CODE <br /> J\ CA <br /> TO BOX (]CORPORATION INDIVIDUAL I� PARTNERSHIP 0 LOCAL-AGENCY <br /> ODISFIC SENCY 0 COUNTY-AGENCY Q STATE AGENCY I� FEDERAL.-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 0 / IF INDIAN RESERVATION #OF TANKS AT SITE E.P.A. 1.D.#(optimal) <br /> 0 8 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMER EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) P):IONE A WITH AREA CODE DAVE:NAME(LAST, T) <br /> 6, 1 P6 I aq1 %3 PHONE A WITH AREA MnP <br /> HTS: NAME(LAST,FIRST) P E#WITH AREA COU ^� NIGHTS: NAME(LAST, STf <br /> P14ONP 8 WITH AREA CODE <br /> it - OV <br /> II. PROPERTY OWNER INFORMATION- ST BE COMPLETED <br /> NAME / � ' CARE OF ADDRESS INFORMATION rA ^ <br /> �qkco <br /> MAILI GOR TREET DRESS ✓ box bintlkaN INDIVIDUAL J VOl'LOCALv-AGENCY I�STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNrY-AGENCY O FEDERAL-AGENCY <br /> CITY N ST TE <br /> ZIP CODEPHONE#WITH�AREA DE <br /> c� o — 66,7301 1 o ( 2CO2 &,25 <br /> III. TANK OWNER INFORMATION• (MUST BE COMPLE D) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa binocals E=j INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ D474 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMFILE D)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMicale O 1 SELF-INSURED Q 2 GUARANTEk 0 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTEROFCREDR E-1 8 EXEMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing 'll 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 LLING: I.❑ 11. 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(PR INTER a SIGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY TY* JURISDICTION a FACILITY x <br /> �`�-- 1 <br /> L0CATIONCODE -OP77ONAL CENSUS TRACT# -OPTIONALSUPVISOR-DIST ICT f�C1D�-OP AL <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) FORW33A 5 <br />