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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD C ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACHOLA ILITYISITE <br /> MARK ONLY Q I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DSAOR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEU IOPTN)NAy <br /> N/7 er <br /> CITY NAME STATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> CABox <br /> 4 <br /> TOINDICATE O CORPORATION O INDIVIDUAL [:�]PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY FEDERAL#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR0 ✓ IF INDIAN J#OF TANKS AT SITE E.P.A. I.D.#(o#Nxn&p <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) P N WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> h <br /> ?I PHONE 2 WITH AREA CODF <br /> NIGHTS: NA (LAST.FIRST) PHONES NTH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> 4A (f/A7 <br /> MAILING OR STREET ADDRESS ✓box bkwxc 0 INDIVIDUAL E:3 LOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION E:1 PARTNERSHIP ED COuNrY-AGENCY E::] FEDERAL#GENCY <br /> CITY NAME STATE I ZIP OGDE 23r2 I PHONE#WITH AREA CODE <br /> SST, <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER ( c>V-/ / — CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS C ✓box blr&b ED INDIVIDUAL L-1 LOCAL-AGENCY 0 STATE-AGENCY <br /> c-0O CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONE#WITH AREA CODE <br /> c��vrT Saves <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER.Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4-1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0 ldloaie Q I SELF-INSURED 2 GUARANTEE L—I 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT 6 EXEMPRON O 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.[=] II.O III. <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION At FACILITY# A..� N(�� aV <br /> �-{-' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3 <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(561) <br /> FOR AS <br />