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t <br /> �oVR <br /> STATE OF CAUFORNIA t^ <br /> STATE WATER RESOURCES CONTROL BOARD W mom, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o w'e . o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT F7 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> y CITY NAME STATE ZIP CODE SIDE PHONE N WITH AREA CODE <br /> v BOX <br /> TO INDICATE 0 CORPORATION En INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1--U;'t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.X(optimal) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS , <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST FIRST) PHPNE x WITH AREA CODE DAYS: NAME(LAST,FIRST) f <br /> NIGHTS: NAM (LAST,FIRST) /.PHON r WITH AREA CODE NIGHTS: NAME(LAST,FIRST) N�?C. �,r./n <br /> /1'I/��✓7,:E ,: r ilj7 r14i� C%%!� '4,: ('�^ n!,��, . ia.v.�t" PHONE Y <br /> CODF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1E hl 61 15 <br /> MAILING OR STREET ADDRESS / ^ ✓ box IoindeM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> >`7 c.. Z D fC `�CJ��� CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHON 0 WITH AREA CODE <br /> 447,C S/f;► << , eD7o7- (a0W 7c- 4 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS / ✓ box IDInd"te Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> fox 6-r35 ®CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STAT� ZIP CODE PHONE M WITH AREA CODE <br /> 1,4 <br /> ' /5 '_' �_ y cA <br /> CT <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO 144 I- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box IDin&ate 1 SELF INSURED 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> IJ 5 LETTEROFCREDIT Q 6 EXEMPTION Q 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.= it. <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 ONTWDAY(YEAR <br /> >� C L '� C !�✓i �Ul,iii +fa eC /�-i�k'1/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION x FACILITY u <br /> 0 ��I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT i •OPTIONAL SUPVISOR-DiSTRICT 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(5-91) FOR0033A.5 <br /> __ <br />