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P <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,n o <br /> I o. <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED_SIT <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ✓F <br /> I. FACILITY/SITE INFORMATION&ADDRESS.(MUST BE COMPLETED) <br /> D OR FA II NEAR <br /> OF OPERATOR <br /> NEAR T ROSS S R ET PARCEL#(OPrIONAL) <br /> A R <br /> STATE ZIPC E / SITE PHONE#WITH AREA CODE <br /> CITU NA _ yCA <br /> BOX <br /> /v1 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY =1COUNfY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> ✓ INDIAN #OFTANKSATSITE E.P.A. I.D.#(,PllW.0 <br /> TYPEOFBUSINESS ❑ t GASSTATION ❑ 2 DISTRIBUTOR 1-1RESERIF VATION <br /> ❑ 3 FARM ❑ 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 AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE g WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓ box 10 WIWI 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> CORPoRATON PMTNEASHIP 0 COUN(Y-AGENCY D FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OW NER <br /> ✓ boa b Indicate0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> 0 <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCV D FEDERALdGENCV <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4:[4]-� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Q <br /> O 2 GUARANTEE 0 EE ED a INSURANCE 4 SURET <br /> 1SELF-INSURED Y BONG <br /> ✓ boa bindicale 0 5 LETTER U CREDIT 0 6 EXEMPTION 0 W 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: I.❑ 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 8 SIGNATURE) <br /> APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY!# JURISDICTION# FACILITY# /�SIJ Z <br /> � Do�� I�f I� - QTS PVS I <br /> LOCATION CODIOT <br /> TIONAL CENSUSTRACT.{ - N EPf� <br /> SUPVISUR-DISTRIG CO E 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 FORr <br /> ONNLLYY. <br /> FORM A(5-91) � 41---- <br /> - <br />