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STATE OF CALIFORNIA eeoon e <br /> STATE WATER RESOURCESZONTROL BOARD c ^ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE ��°`°""'" <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> O7 PERMANENTLY CLOSED SITE <br /> ONE ITEM <br /> (❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA CILITV NAME ' <br /> n NAME OF OPERATOR <br /> A DRESS -- /KS <br /> ��� NEAREST CROSS STREET PARCEL#(OPrIONAO <br /> CITU NAME <br /> STATE ZIP COjjS ITEP ONE%WITH AREA CODE <br /> CAv Box <br /> o <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP (]LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY <br /> DISTRICTS D FEDER4LAGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR II ✓ IF INDIAN O OF TANKS AT SITE E.P.A. I.D.q(optional) <br /> 3 FARM RESERVATION <br /> ❑ ❑ 4 PROCESSORNo 5 OTHER OR TRUST LAN DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) - <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME_ �R14 �� f CAREOF ADDRESS INFORMATION <br /> MAIL17NGh�+10Zli 1DRESS_ � /+\/f ' <br /> 7— ,(,/nJ� Q/� ✓ box blndkaW D INDIVIDUAL Q LOCAL-AGENCY <br /> �6A '/�(/ /`.IJ ' CORPORATION OSTATE-AGENCY <br /> CITY NA E -1 PARTNERSHIP 0 COUNTY AGENCY D FEDERAL-AGENCY <br /> � /I a t „ STATE ZIP CODE PHONE*WITH AREA CODE - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> r-s��,l <br /> MAILING OR STREET ADDRESS ✓ box bintlkale <br /> _ C <br /> �I\ nn 0 INDIVIDUAL QLOCALAGENCV I� STATE-AGENCY <br /> CIT AM�ir/E �--�- , f'�/I/`+( 1 �`•�J O TCORPORATION Q PARTNERSHIP (] OUNTY#GENCV Q FEDERAL-AGENCY <br /> //P,G�.•//V1/�/� ST ZIP COP PHONE x WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER--Call(9196)323-9555 it questions arise. { <br /> TY(TK) HQ L4�-[-L� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b Indicate L7 1 SELF INSURED [-12 GUARANTEE 0 3 INSURANCE 0/SURETY BOND <br /> L� 5 LETTEROFCREDIT E-16 EXEMPTION L7 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: <br /> I ❑ Ilf\lC 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) APPLICANTS TITLE <br /> DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY N <br /> SC ONLY <br /> COUNTY u JURISDICTION# <br /> FACILITYu <br /> LOCATIONCODE -OPTIONAL CENSUSTRACTu _ - -- —— S�--- <br /> OPTIONAL UPVISOR-DISTRICT CODE -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 0 <br /> FORM A(12-9D FILE THIS;FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> T <br />