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STATE OFCALIFORNIASTATE WATER RESOURCES CONTROL BOARO <br /> •o + e <br /> C---iUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH F LRY/SRE <br /> =ONLYI NEW PERMIT � 3 RENEWAL PERMIT <br /> CHANGE OF INFORMATN3N ❑ 7 PERMANENTLY CLOSED SRE2 INTERIM PERMIT ❑ < AMENDED PERMIT <br /> ❑ 8 TEMPORARY SITE CLOSURE O <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY N/AME <br /> NAME OF OPERATOR <br /> ADDRESS <br /> CITY NAME <br /> 711 n NEAREST CROSS S7gEET PAEL#(OPTIONAy <br /> �K Ste'/ RC <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> TO INDICATE ORPOgATION =INDIVIDUAL (]PARTNERSHIP O LacAL-AGENCY <br /> DISTRICTS 0 COUNTYAGENCY 0 STATE AGENCY 0 FEDERALAGENCY <br /> TYPE OF BUSINESS ❑ T GAS STATION TRIBUTOR ✓ IF INDIAN #OF TANKS A7 SITE E.P.A, L p-#(�p„NI <br /> ❑ 3 FARM 1 Pq ----- ❑ 5 OTHER OOq TRUSTVLANOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST.FIRST) ti PHONE#WITH AREA COPE <br /> DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIR$1) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED =ARIFA 10111 <br /> NAME <br /> - CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ ma 0iximu <br /> 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CITU NAME O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL#GENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE Of ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ ma bimkau <br /> 0 INDIVIDUAL O LOCAL-AGENCY O gTATE-AGENCY <br /> 0 <br /> CITY NAME CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY C3 FEDERAL#GENCV <br /> STATEZIP 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 F4-F4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFYTHEM (S) USED <br /> ✓im Ia wkm 0 1 SELF-INSURED 0 t GUARANTEE <br /> O 5(ETTEROFCREOIT 3 INSURANCE O A SURETY SONO <br /> 0 8 EXEMPTION O g9 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L II,❑ III ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSNAAIE(PRNTED&SIGNATURE) APPLICANTS TIRE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION x C FACILITTY0 <br /> LOCATION CODE -OP� CENSUSTRACTa-OPTIONAL SUPVISOR.DISTRICT000E -OPTIONAL <br /> —2-3 OPO <br /> 1 3110- <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) <br /> FORO#3A-5 <br />