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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ycj o <br /> COMPLETE THIS FORM FOR EACH F ILRYISITE <br /> MARK ONLY I7 I NEW PERMIT 7 D RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT <br /> ONE ITEM [D 2 INTERIM PERMIT Q d AMENDED PERMIT 06 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OSAORFACILITYNAME - NAME OF OPERATOR <br /> _ <br /> Omm <br /> ADDRESS n NEAREST CROSS STREEWz, vO PARCEL+(OPnONAU <br /> CITY NAME STATE ZIP ftoiz I SITE PHOAE+WITH AREA CODE <br /> CA <br /> ✓ Box CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL AGENCY <br /> TOINpCATE DISTRICTS <br /> TYPE OF allSINESS O T GAS STATION Q 2 DISTRIBUTOR Q <br /> RESERVATION <br /> IF INDDIAN a OF TANKS AT SITE E.P.A. L D.a(optimal) <br /> Q 3 FARM Q d PROCESSOR S OTHER OR TRUST LANDS L/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA COOS DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PWONC a WITH ARP CCQP <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WXbM,,Ale Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ W.0NKale Q INDIVIDUAL Q LOCAL-AGENCY Q STATEAGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDEMIL AGENCY <br /> CITY NAME STATE ZIP CODE I PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 't7 3 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THEM D(S) USED <br /> ✓bm biMkYe 0 1 SELF-INSUREO 0 2 GUARANTEE Q INSURANCE Q A SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 5 EXEMPTION R2 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: L 0 It.[�] III.= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION p FACILITY N <br /> OTGoM/ D /b-tel <br /> LOCATION CODE - T NAL ICENSUSTRA Ta -rONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> q:j <br /> F <br /> THIS FORM MUST ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• ORM B,UNj THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOR003A 5 1 <br />