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Peou. e <br /> P <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> T' UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A P oe <br /> C�II�OPNP <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANEN <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FArE.- 5 NAMEOF OPERAT <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 203 Sx L�, ncn <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �cc CABOX <br /> /c53 <br /> TO INDICATE D CORPORATION [ VIDUAL 0 PARTNERSHIP DLOCAL <br /> RI-AGENCY 0 COUNTY-AGENCY STATE AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR / <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.0.#(optional) <br /> O 3 FARM 4 PROCESSOR = 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) PHONE*WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS Tt PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE 4 WITH AREA Coni, <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME !� CARE OF ADDRESS INFORMATION <br /> �,—, }� ; S <br /> MAILING OR STREET ADDRESS ✓ box bin&cate INDIVIDUAL O LOCAL-AGENCY D STATE AGENCY <br /> L L l C c> O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> eca 55336 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate [71 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTYAGENCY 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 TT- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boz binEkale O 1 SELF INSURED 0 2 GUARANTEE 3 INSURANCE d SURETY BOND <br /> O 5 LETTEROFCREDIT = 6 EXEMPTION 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: I.O IL 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) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COU�NTV# JURISDICTION# FACILITY# ZL/ <br /> IL—JI I ^I��13 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT - SUPVISOR-DI ICT CODE .OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT L 'ST(1)0 PLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO / TI NLY. <br /> FORM A(5-91) p FOR0033 <br />