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�}OaA <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :am <br /> Ci(Inp�N,n i <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEO,S$ <br /> ONE ITEM 2 INTERIM PERMIT Q d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAQRFA ILITY NAME NAMEOF OP ATOR . /1 x <br /> ADDR 3 / //-- NEAREST OSS STREET U PARCEL#(OP(OPTIONAL) <br /> 5/d <br /> CI N E STATE ZIPC E��2 SITE PHONES WITH AREA CODE <br /> Ky4pw CA <br /> TO INDICATE CORPORATION �INDIVIDUAL l�PARTNERSHIP LOCAL-AGENCY DISTRIl�COU✓ZKfY-AGENCY? 0STATE-AGENCY l� FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION ] 2 DISTRIBUTOR RV <br /> IF INDDIAN SOF TAN�(S AT SITE E.P.A. I.D.N(apfbnaQ <br /> O 3 FARM O A PROCESSOR O 5 OTHER OR TRUST LANDS Z <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE S WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE&WITH AREA r011F <br /> NIGHTS: NAME(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA COOP <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ baxbmAbau INDIVIDUAL E-1 LOCAL-AGENCY E�j STATE-AGENCY <br /> CORPORATION D PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONES 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 Mitala 0 INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDEPAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -1013 IZI-24 Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ Cox blMkale O I SELF-INSURED UARANTEE 0 3 INSURANCE d SURELY BONG <br /> 0 5 LETTER OF CREDIT EY6 EXEMPTION I= 66 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.—71 <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= 11.[:—] III.E <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY /1, /I <br /> COUNTyp (Nx•y JURIS 1t FACI� <br /> 'Ip��TJI`I7f�I1 <br /> LOCATION E -OPTIONAL CE SU TRACCTl,#✓^OPTIONAL SUPVIS-�OR-DISTRK:T CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AAT LEAST(1)((1)OR MORE PERMIT APPLICATIONS• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A Is91) FORMA 5 <br /> `� A� <br />