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a <br /> STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR CILRY/SITE <br /> MARK ONLY U;17N% PERMIT 3 RENEWAL PERMIT 5 HANGE OF INFORMATION EE T PERMANE TLLD SITE <br /> ONE ITEM Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACT /SITE INFORMATION&ADDRESS-(MUSLIllIfE COMPLETED) <br /> DBAOR CILITYNAME NAME OF OPERATOR <br /> ADORE S ^ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAM //✓( S TE ZIP CODE <br /> aDx C; SITE PHONE#WITH AREA CODE <br /> ✓ <br /> TOINgCATECORPoRATION INDIVIDUAL PARTN RSHIP Q LOCA AGENCY COUNTY-AGENCYl�STATE-AGENCY FEDEML#GENCY <br /> DST TS <br /> TYPE OF BUSINESS O 1 GA TION Q 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(apthmal) <br /> RESERVATION tr <br /> Q 3 FARM .4PROCESSOR 5 0 OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE WI H AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME ULA87,FIRST)f PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boabM WO INDIVIDUAL L—1 LOCAL-AGENCY O STATE#GFACY <br /> O CORPORATION f� PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa b Micah 0 INDIVIDUAL LOCAL-AGENCY O STATE AGENCY <br /> =CORPORATION 0 PARTNERSHIP COUNTY AGENCY FEOERAL-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 F4-F41- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa 0IndbaN i SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY WNO <br /> 0 5 LETTER OFCREDIT Q 6 EXEMPTION 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:] I.0 III.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY /i✓✓� <br /> COUNTY# Jj tl JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT## -OPTIONAL SUPVIS -DISTRICT CODE -OPTIONAL <br /> O � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF INFORMATION ONLY, <br /> FORM A(5-91) FOR=3A-5 <br />