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STATE OF CALIFORNIA °a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� <br /> 4 � O <br /> onNN <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE REM T441INTERIM PERMIT 0 4 AMENDED PERMIT [_] B TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACILITY AME NAMEOFOPERATOR <br /> ADDR SS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY MIXE r STATE ZIP ODE1 SITE PHONE#WITH AREA CODE <br /> CA <br /> I/ aox <br /> TOINgCATE D CORPORATION 0INDIVIDUAL (] PARTNERSHIP LOCAL AGENCY 0 COUNTY-AGENCY OSTATE-AGENCY 0 FEDERALdGENCY <br /> DISTRICTSTRICTSTRICTS <br /> TYPE OF BUSINESSO t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(oplianalJ <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION 3 <br /> O O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMAR EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMAT N• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa bindbat# D INDIVIDUAL O LOCAL AGENCY 0 STATE AGENCY <br /> (]CORPORATION = PARTNERSHIP M COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> MTY NAME STATE ZIP CODE PHONE­­HWITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST ECOMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ box 0 wical# 7] INDIVIDUAL 0LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION = PARTNERSHIP (] cOUNrY-AGENCY (] FEDERALAGENCV <br /> CITY NAME- STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEECCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4 I`' -' FF1_J= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(M TBE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ W.bimica. [] I SELF INSURED =2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOUD <br /> (] 5 LETTEROFCREDIT 0 6 EXEMPTION 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal Itification 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.0 II.O 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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY 3_3 <br /> COUNTY At JURISDICTION# FACILrv# <br /> 311 L1-j- I Ia <br /> LOCATION COD 'g7pTIONAL (CENSUS AC # -OP NAL SUPVISOR-DIST`$�JT ODE -OPTIONAL <br /> . ^ / o" .. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OW-Y. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> o< K ; ss 14Z a- ,.,rte -/� ` �3yts P6 i <br />