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1111100 *-me <br /> STATE OFCALIFORMA op <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SRE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 'L <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR /� <br /> Z �1• /�F-A/Z <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITU NAME STAE ZIP�CODE SITE PHONE#WITH AREACODE <br /> CA <br /> BOX <br /> TO INDICATE 0 CORPORATION erINDIVIDUAL 7] PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS l.�J - STATION L 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION / <br /> FARM Q 4 PROCESSOR � 5 OTHER OR TRUST LANDS OpO 6I ZS6d <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) *WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> AAW 7— .t-� • G . car - oa <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I NIGHTS: NAME(LAST.FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ! �� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa biMicalaIDUAL O LOCAL-AGENCY L__3 STATE-AGENCY <br /> =CORPORATION = PARTNERSHIP 11 COUNTY-AGENCY O FEDERALAGENCY <br /> Cl/4NA44'AfP6 ME CZI� E ZLd � ITH AREA ODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) 3 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 7— <br /> MAILING <br /> MAILING OR 45dSTREETADDRESS ✓ bar 0Mule INDNIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> D _ �� �� =CORPORATION = PARTNERSHIP O COUNTY-AGENCY FEDERALAGENCY <br /> CW2 ME STATE ZIP CODE PHONE WITH AREA CODE <br /> ZZ� ZaR - 4oR <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 U Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> boo kwcab O 1 SELFFINSURED O 2 GUARANTEE O 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION O IS 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 II.�/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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TR`CT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL- R <br /> THI_IS7FORM 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) FORMA-5 <br />