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STATE OF CALIFORNIA A P <br />Q.6��N es <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EA/FACILITY/SITE <br />MARK ONLY F7 1 NEW PERMIT F_� 3 RENEWAL PERMIT EV5 CHANGE OF INFORMATION E 7 PERMANENTLY CLOSED SITE <br />ONE ITEM F-1 2 INTERIM PERMIT O 4 AMENDED PERMIT E 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA FAC4ITY NAME � n� � <br />NAME OFPFE BATOR <br />DAYS: NAME (LAST, FIRST) <br />PHONE <br />/ <br />ADDREZ2 <br />NEAR TCROSpSTRREEET <br />PARCEL (OPTIONAL) <br />LOCAL -AGENCY STATE -AGENCY <br />L / <br />CITY44 <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />STAT <br />CA <br />PHONE #WITH AREA CODS 530D <br />✓ BOX <br />TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR"RESERVATION <br />IF INDIAN <br /># OF TANKS A SITE <br />E. P. A. I. D. # (optional) <br />3 FARM 4 PROCESSOR 5 OTHER <br />OR TRUST LANDS <br />1 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME,Aee,l) � <br />C <br />CARE OF ADDRESS INFORMATION <br />✓ box to indicate [_�] INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY <br />I] CORPORATION 0 PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />MAILI O�TREETA RESS/ <br />STATE <br />✓ box to indicate INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />L / <br />0 CORPORATION PARTNERSHIP <br />] COUNTY -AGENCY FEDERAL -AGENCY <br />CI ME 0_ <br />STAT <br />ZIP CODE ' �D� � <br />PHONE #WITH AREA CODS 530D <br />III. TANK OWNER INFORMATION. (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate [_�] INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY <br />I] CORPORATION 0 PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # 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 - 0 <br />V. PETROLEUM UST FINANCI RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br />i= 5 LETTER OF CREDIT 0 6 EXEMPTION 93 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II i checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. a II. III. ❑ <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) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # - JURISDICTION # FACILITY # <br />391 fifi&5,9/ = - l 3 6 l *-- <br />LOCATION CODE' - OPTIONAL CENSUS TACT #` - pPDONAL SUPVISOR - DISTRICT j ODE -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 bNLY. <br />FORMA (5-91) n� FOR0033A-5 <br />