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G 14� � yrs °" e. <br /> STATE OF CAUFORMA � <br /> STATE WATER RESOURCES CONTROL BOARD �� o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �; <br /> C�x�-on M�� <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSE <br /> D AMF <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE �f <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) CJ <br /> DBA 9jLFAC1UTY NAME NAME OF OPERATOR <br /> I At F /o TRA) k [:i J�1_� <br /> ADD NEAR ST CROSS STREET PARCEL#(OPTKINAfJ <br /> A <br /> CITY NAME STA Z CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> Box <br /> i01NgCATE RPoRATION (] INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION —1 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(rolbnaQ <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> 0 OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIR PHONE#WITH AREA CODE DAYS: NAME( ST,FIRST) <br /> NIGHTS: NAME(LAST,FIR PHONE x WITH AREA CODE NIGHTS: NAME(L T,FIRST) PHONE a WITH AREA rIn <br /> 11. PROPERTY OWNEINFORMATION- MUST BE COMPLETED) WITH ABEA CO <br /> NAME CARE OF ADDRESS I ORNATION <br /> MAILING OR STREET ADDRESS ✓ box bindb INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATI N.(MUST BE COMPLETED) <br /> NAME OF OWNER CAREOFADDRESS INFORMA ION <br /> MAILING OR STREET ADDRESS ✓ box b,M"WW O INDIVI AL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> O CORPORATION Q PARTSHIP (] COUNTY-AGENCY (] FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST ST RAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if estions arise. <br /> TY(TK) HQ 14L. r <br /> V. PETROLEUM UST FINANCIAL RESPON IBILITY-(MUST BE COMPLETED)—IDENTIFY THE OD(S) USED <br /> ✓ box roiMicale I SELF INSURED 0 2 GUARANTEE 0 SINS AHCE 0 A SURETY BOND <br /> 5 LETTEROFCREDIT ��6 EXEMPTION 98 OTHkR <br /> VI. LEGAL NOTIFICATION AND BILLING ADD ESS Legal notification and billing will be sent to the tank owns unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD E USED FOR LEGAL NOTIFICATIONS AND BILLING: 11.� III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PEN LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS T E AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY RaAlm IS Ip <br /> COUNTY# JURISDICTION# FACILITY# O AO 3 <br /> �3q1 I _I I <br /> LOCATION COOE -OPTIONAL ICENSUSTRACT# -OPTIONAL ISUPVISOR-DISTRICTCODE -OPTIONAL <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 112.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> _ <br /> vow <br /> FON .R <br /> N <br /> l <br />