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14d <br /> STATE OF CALIFORNIA " e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT AP LICATION - FORM A <br /> COMPLETE THIS FORM FORE FACILITY/SITE •`'� <br /> FMARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br /> ONE REM 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS E <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> OADDRESS � NAME OF OPERATOR <br /> k- `[C( <br /> NEAREST CROSS STREET PARCEL i(OPTIONAL) <br /> STATEZIPCOD CA Z�RPORATION 0 INDIVIDUAL 0 PARTNERSHIP ED LOCA4pGENCY Il COUNTY-AGENCYDISTRICTS C7 STATE-AGENCY O FEDERAL-AGENCY <br /> GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN i OF TANKS AT S . . . I.D.FARM 4 PROCESSOR ❑ 5 OTHER ORTRUST <br /> LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) optionalGAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST <br /> NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P,InNF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> [NAMEIAJ (I � AREOFADDRESSING RSTREET ADDRESSbox bindioma1 2OINDIVIDUAL0 LOCAL-AGENCY 0STATE-AGENCY <br /> AME !!✓✓ CORPORATION I0 PARTNERSHIP 11:1 COUNTY AGENCY 1–D FEDERALAGENCY <br /> S w STATE ZIP C�OyDE PHONE IF WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> =NAMEOFOWNEmE OF ADDRESS INFORMATION <br /> -- _ — -- _ -- <br /> — 0 INDIVIDUAL 0 LOCAL-AGENCY [�STATE.AGENCY <br /> — - CORPORATION 0 PARTNERSHIP 0 COUNTV-AGENCY 0 FEDERAL-AGENCY <br /> STATE 21P CODE PHONE i 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 4�- a y G <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box rointl¢ba 1 SELF INSURED [�2 GUARANTEE 3 INSU <br /> 5 LETTEROFCREDT 6 EXEMPTION L]THEA 4 SURETY BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless boX I f is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.EjK it.D III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSNAME(PRINTED It SIGNATURE) APPLICANTS TITLE <br /> DATE MONTH/DAYIVEAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# i - FACILITY# Irl l7W V 9/ <br /> 3 y <br /> LOCATION CODE -OP❑ONAL IGENSUS TRACT -OPTIONAL ISUPV OR DISTRICT CODE OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE IN RMATION ONLY. <br /> FCRM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOHW33A A6 n <br /> ` A <br /> Now <br /> A <br />