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`• STATE OF CALIFORNIA ...... <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> re <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O LOSE^ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 7 PERMANENTLY CLOSED SI <br /> ❑ 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> KADD <br /> OR FACILITY NAA , NAME OF OPERATOR <br /> RESB �j( <br /> NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> E5 l C l 7 L — <br /> CITY NAME <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> V,Box TO CORPORATION Q INDMDUAL Q PARTNERSHIP Q LOCAL-AGENCY ED FEDERAL-AGENCY' <br /> oenero LIS DISTRICTS COUNTY-AGENCY' [:D STATE-AGENCY' <br /> 'Xewnard UST'sepubfne ,MvIm8thefuAOwn1r rINned smerviwrd dMWm,Wien m0#Re which 01)"es the UST <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.0.M(optroneq <br /> ;—a <br /> 3 FARM ❑ 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST(ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> [NIGHTS: <br /> AYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1 -0 � — L <br /> MAILING OR STREET ADDRESS ✓ box w h&me INDMDuAL E:j LOCAL-AGENCY O STATE-AG <br /> 7 <br /> I— 3 �<CORP@UTION O PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE21P CODE PHONE#WITH AREA CODE <br /> t S — 5 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> (} P <br /> MAILING OR STREET ADDRESS// ✓ b#s1#ndioU INDIVIDUAL0LOCAL-AGENCY I1 STATE- ENC; <br /> �U x.13 � =CORPORATION O PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1 2- <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- "�11U l <br /> V. PETROLEU ST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bm to iMeale ISELF-NSURED O 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND =5 LETTEROFCREDIT O 6 EXEMPTION O 7 STATE FUND <br /> X STATE RIND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE RIND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM O 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: 1.0 11.W <br /> III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK <br /> DATE MONTHlDAY/YEAR <br /> OWNER'S NAME TANK OWNER'S TITTLE <br /> AaLND <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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 6NLY. <br /> OWNER MUST FILE THIS FORM' -i THE LOCAL AGENCY IMPLEMENTING THE UNDERGROV""STORAGE TANK REGU ATIONNS1)�`"{�S <br /> FORM A(5-95) *awl I..000to�.{ 5p <br />