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\ ' eeeoun e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> O M <br /> COMPLETE THIS FORM FOR EACH ILRY/SRE <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOIE <br /> ONE REM '-1 2 INTERIM PERMIT Q 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE 6 r <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACT AME NAME OF OPERATOR <br /> Q _ <br /> ADDRESS NEAREST CR(1SS STREET PARCEL#(OFnONA0 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA S <br /> ✓ BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERS Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS J GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(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) PHONE#WITH ARE DE DAYS: NAME(LAST,FIRST) <br /> NIG AME(LA T, IRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE*WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box 10 Wle W Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q coUNrYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box xiMkale Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO `4141-n--17r= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box toindkale F--j I SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETVBOND <br /> Q 5 IETTEROFCREINT L=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: 1.O 11.0 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 B SIGNATURE) APPLICANTS TITLE DATE MONDAY EAR) 93 <br /> LOCAL AGENCY USE ONLY Z 3 w <br /> COUNTY# JURISDICTION# FACILITY# <br /> - 1- o <br /> LC1(:ATION CODE -OPTION L CENSUSTACT# -OP_ TIO y. SUPVISOR-DISTRICT CO P710NAL <br /> THIS FOR 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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO ` <br /> —\ FOP003JA16 <br />