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ltyOUx pg C <br /> STATE OFCALIFORNIA �� <br /> a <br /> _ STATE WATER RESOURCES CONTROL BOARD 3 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w � �e <br /> .a ' r, o <br /> i-UNN� <br /> ICOMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT I� 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT LJ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O F -ITYy/APE I �� /� NAME OF OPERATOR <br /> 7 <br /> AD E / NEAR TCROSS EET PARCEL#(OPTIONAL) <br /> CITY N E STATEZIP ZOO SITE PHONE#WITH AREA CODE <br /> CA <br /> I/ BOX <br /> TO INDICATE CORPORATION (] INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNrY AGENCY (] STATE-AGENCY 0 FEDERAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR D RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(op#mal/ <br /> 0 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optimal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHnN9 A WITH AREA CMP <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAsti CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa b Fiat# (] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION PARTNERSHIP = COUNTYAGENCY FEDERAL-AGENCY <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- bmbiM ma = INDIVIDUAL IF1 LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATATIOONN�UST <br /> ySTORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14:141- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Wx In 1 SELF-INSURED (] UARANTEE 0 3 INSURANCE O 4 SURLTBOND <br /> O 5 LETTEROFCREDIT 6 EXEMPTION =1 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' ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O ]I.e H. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIONC(]QE/OPTIONAL (CENSUS TFO, OPONAL SUPV�07 STRICT CODE -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 Ila 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGR STORAGE TANK REGULATIONS <br /> 3�D✓t �33A F6 <br />