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• • ,OVRC[ <br /> p C <br /> STATE OF CALIFORNIA �° `; <br /> STATE WATER RESOURCES CONTROL BOARD w��, u a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> i R' �.x,.o�°.. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ d NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 2 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> G�oD <br /> v;6-00— g" i <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> LDI= <br /> CITU NDAME T' STACA -7 ZcZ b IP ITE PHONE WITH AREA CODE <br /> ( TO I/ BOX <br /> INDICATE (]CORPORATION (] INDIVIDUAL [j]PARTNERSHIP 0 LOCAL-AGENCY =1 COUNTY-AGENCY STATE-AGENCY L-:] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ I GAS STATION 2 DISTRIBUTOR ❑ q SEIF INDIAN RVATION #OF TANKS AT SITE E.P.A. 1.D.x(opllarali <br /> 3 FARM O 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) PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> a A VT ' S <br /> MAILING OR STREET ADDRESS ✓ boxbindkate INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> 1z- - �02 A CORPORATION O PARTNERSHIP D COUNTY-AGENCY D 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 /> To - G- <br /> MAILINGORSTREETADDRESS ✓box bindkala Q INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> �Yl�".. - O CORPORATION D PARTNERSHIP O COUNTY AGENCY Q FEDERAL-AGENCY <br /> CNAME STAT ZI � !� PHONE#WITH AREA CODE <br /> I7o0� ,7l <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 44 -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindkate 0 t SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE [_1 d SURETY BOND <br /> O 5 LETTEROFCREOIT D 6 EXEMPTION O 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.❑ 11.❑ U. <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 MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY cc <br /> C4 <br /> COUNTY# JURISDICTION# L # <br /> Ob <br /> LOCAQTION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE .OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED 13Y AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(5.91) PC <br />