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r <br /> STATE OFCAUFORNIA % esounca <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A v8 <br /> 2 . . o <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE ^ o^"`°^"'^. <br /> MARK ONLY ❑ 1 NEW PERMIT ❑F� 3 RENEWAL PERMIT IF:] 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT L—J 4 AMENDED PERMIT <br /> ❑ 6 TEMPORARY SITE CLOSURE y <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) C_ <br /> DRADB FACILITY NAME <br /> NAME OF OPERATOR <br /> AUUMLSS <br /> NEAREST CROSS STREET PggCELNIOPfgNAL) <br /> CITY AME <br /> tooL/(//�•r'v STATE ZIP C ITE P ONE N WITH AREA CODE <br /> �/ �_- CA RjZ D <br /> TO INDICATE O CORPORATION O INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY <br /> DISTRICTS O STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN MOF TAryKS AT SITE E.P.q. I. ,(opN�al) <br /> ❑ 3 FARM ❑ VAII <br /> 4 PROCESSOR 5 OTHER OOR TRUST LANDS I/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAS FFIRSn PHONE%WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRSR <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STRE TADDRESS <br /> G_ <br /> INDIVIDUAL Ell LOCAL AGENCY ESTATE AGENCY <br /> COUTYGENCY CNA CORPORATION Q PARTNERSHIP Q <br /> FEDERAL-AGENCY <br /> p� STAT ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNEq r— � A �O � A CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 'LTJ-, <br /> ✓ bov biMkale Q INOIVIDUAI <br /> 0 LOCAL-AGENCY (�STATE-AGENCY <br /> CI 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> ADASTATE- ZI� PHONE*WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)3233-9�questions arise. <br /> TY(TK) HO L4 141-El— <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate I SELF INSURED 2 GUARANTEE 31NSURANCE <br /> 5 LETTER OF CREDIT6 EXEMPTION O a SURETY BOND <br /> _J IR OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sen(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 ,,��,,// <br /> 1 ❑ 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&SIGNATURE) APPLICANTS TITLE <br /> DATE MONTWDAVNEAR <br /> LOCAL AGENCY USE ON <br /> AGENCY uac vlvcY <br /> :OPTIONAL <br /> Y# JURISDICTION# <br /> FACILITY# <br /> _ _ LLO(, TON CODE CENSUS TRACTp -OPTIONAL <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3- <br /> THI FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A u ,en FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> Foga <br />