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STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br />pespOR <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />e <br />COMPLETE THIS FOflM FOR EACH FACILITYISITE �"'��""'' <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT <br />ONE ITEM ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />❑ 2 INTERIM PERMIT ❑ q AMENDED PERMIT <br />❑ e TEMPORARY SITE CLOSURE Q <br />I. FACILITY/SITE INFORMATION & ADDRESS • (MUST BE COMPLETFm <br />OO �•- / DP ;r V� NEARE <br />+` !/ <br />CITY NAME � <br />STATE <br />✓ Pox CA <br />TO INDICATE OgPoRATION 0 INDIVIDUAL I= PARTNERSHIP Q LOCA4AGEN <br />TYPE OF BUSINESS DSTRICTS <br />T GAS STATION ❑ 2 DISTRIBUTOR ❑ <br />❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR <br />EMERGENCY CONTACT PERSON (PRIMARY) <br />DAY%jj gi.(«In PHONE #WITH AREA <br />II. PROPERTY OWNER INFORMATION - (MUST BE <br />NAME <br />CARE <br />TANK OWNER INFORMATION - (MUST BE <br />OF OWNER . <br />ZIP <br />5Z-ea <br />a rn NE # WITH AREA CODE <br />Tit 333 — W.!� <br />COUNTYAGENCY 0 STATE -AGENCY O FEDERAL -AGENCY <br />SITE I E. P. A. I. D. # (optionyJ <br />EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />0 INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />= PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY <br />Y mX10001C21B <br />b� � 4/ v� 0 INDIVIDUAL (] LOCALAUMCY STATE -AGENCY <br />CITY NAME a Ate- BPORATION PARTNERSHIP COUNfYAGENCY (] FEDEML-AGENCY <br />_ STATE 21P CODE / HONE #+KITH E CODE <br />ars/ C:7 ,' /�J `��2-E�aa <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER -Call (916)32.-9..b if questions arise. <br />TY (TK) HQ 4 4 fj <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY • (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ bw bNicee 1 3ELF-INSURED Q 2 GUARAMEE 0 6 INSURANCE <br />O 5 LETTEROFCREOIT 6 EXEMPTIONQ 99 OTHER ] 4 SURETY BOND <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 ❑ it III <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # <br />� �FACILITY:�# �� <br />LOCATION CODE - OPTIONAL CENSUS TRACT# OPTIONAL = _ G' " G - <br />3.� S�PVIS'ORiDISTRICTCODE OP70NAL <br />THIS FORM MUST BE ACCOMPANIED By AT LEAST <br />FORMA (5-91) (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />/e/� � FORW7^JA.5 <br />