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a t9 <br /> STATE OF CALIFORNIA ��5Ju `�. <br /> STATE WATER RESOURCES CONTROL BOARD ; a< <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ;' <br /> COMPLETE THIS FORM FOR EAC CILTTYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE D <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEPER TOR <br /> C. �c Sher an <br /> ADORESL� LI NEAREP CROSS STREET PARCEL#(OPTIONAL) <br /> onor <br /> CITY NAME ST CA <br /> ZIP OQDE6zo S TE PHONE A WITH AREA CODE / <br /> I/ BOX <br /> TO INDICATE 0 CORPORATION INDIVIDUAL O PARTNERSHIP [—ILOCAL-AGENCY0 COUNTY-AGENCY STATE-AGENCY/—I FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 RESERVATION AN #OF TANK SITE E.P.A. 1.D.#(optimal) <br /> O 3 FARM Q 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WX bindicate D INDIVIDUAL O LOCAL AGENCY STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <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 ✓ Wx b indicate INDIVIDUAL LOCAL-AGENCY OSTATEAGENCY <br /> I�CORPORATION O PARTNERSHIP 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) HQ 4 41_101 Z Lf 151(c <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Dx 0 dicate O I SELF-INSURED El 2 GUARANTEEQ SDRANCE D 4 SURETY BOND <br /> 5 LETTEROFCREDT =6 EXEMPT ON 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.❑ IL❑ 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 S SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY n�'"" Qy�LL— <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3M M i rco 5/0 <br /> LOCATION CO E -OPTIONAL CENSy$,T T#TIONAL SUPVISOR-DISTRIC CODE -OPTIONAL \ <br /> THIS FORM MUST 0E ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM_A(5-91) (FOR0070A.5 q <br />