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• <br />STATE OURCES ON Ply <br />STATE WATER RESOURCES CONTROL BOM <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />" COMPLETE THISFORM FOR EAC FACILITYISITE <br />MARK ONLY ❑ 1 NEW PERMIT F73 RENEWAL PER <br />5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION&ADDRESS - (MUST BE COMPLETED) <br />DSA OR FACILITY NAME <br />NAME OF OPERATOR <br />d <br />M ING OR STREET ADDRESS <br />+ <br />7Q/ OGG �- <br />ADDRESS <br />NEAREST CROSS STREET <br />PMCEL#(OPTIONAy <br />0,0p lif/, ii0�” [�� <br />liflKJ-5;0<n- <br />GCITY <br />H a WITH AREA CODE <br />CITYNAME <br />STATE <br />ZIP COOED. <br />S PHONE WITH AREA CODE <br />Q STATE -AGENCY <br />A <br />C <br />3 ___,��D/, <br />✓ Box�Gi• <br />TO INDICATE ORPORATKIN Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE.AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS TION ❑ 2 DISTRIBUTOR <br />Q ✓ IF INDIAN <br />N OF TANKS AT SITE <br />E. P. A. I. D. # (Rotima# <br />Q 3 FARM O 4 PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST. FIRST)PHONE #WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />d JG <br />M ING OR STREET ADDRESS <br />+ <br />7Q/ OGG �- <br />NIGHTS:NA FIRST) p WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) <br />��ME(LAST, PONE <br />STA <br />ZIP CODE <br />H a WITH AREA CODE <br />II- PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />as A, • <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />M ING OR STREET ADDRESS <br />+ <br />7Q/ OGG �- <br />✓ iMNme Q INDIVIDUAL <br />CORPORATION Q PARTNERSHIP <br />Q LOCAL -AGENCY Q STATE AGENCY <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CIN NAME L <br />STA <br />ZIP CODE <br />PHONE N WITH AREA CODE <br />II- TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OW NEA <br />CARE OF ADDRESS INFORMATION <br />�, G <br />MAILING OR STREETADORESS <br />✓ bo iWi Q INDIVIDUAL <br />Q LOCAL -AGENCY <br />Q STATE -AGENCY <br />CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY <br />Q FEDERAL -AGENCY <br />CITY NAME <br />STATE ZIP CODE <br />ONE # W TH ARE CO,DE— <br />O <br />IV. BOARD OF EQUALIZATION US STORAGE FEE ACCOUNT NUMBER - Call (916) 323.9555 if questions arise. <br />TY (TK) HQ 14T4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED <br />✓ Eox minAkaw L� I SELF-INSURED = 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br />O 5 LETTER OF CREDIT Q 6 EXEMPTION 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank 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. ❑ II. Z IN. ❑ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE ANDtORRECT <br />APPLICANTS NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />�_: <br />LOCATIONCODE OPTIONAL CENSUSTRACT# OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <br />a Zr L 3. gy 3ZD <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION • FUHM H, UNLESS THIS 15 A CHANGE OF 511 E INFUHMA I IUN UNLT. <br />FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TA LAT NS F AR6 <br />�� <br />