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• <br /> STATE OF CALIFORNIA �e eOq <br /> STATE WATER RESOURCES CONTROL BOARD '; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE le <br /> MARK ONLY ❑ 1 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 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> �L-/Z�c-ntl v <br /> ADDRESS ^ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX O CORPORATION Q INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' lD STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #owneral UST u apublic agency,=plate the folimbig:name d supervisor d division,section ara#ice which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAs STATION Q 2 DISTRIBUTOR ❑ ✓IF INDIAN #OF TANK AT SITE E.P.A I.D.#(optianaq. <br /> RESERVATION <br /> 3 FARM Q 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ baxW ix9rab INDIVIDUAL <br /> �L � �LOCAL-AGENCY O STATE-AGENCY <br /> 3C Q O CORPORATION = PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE <br /> PHONE#WITH AREA CODE <br /> dl5ZZ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Io Whale Q INDIVIDUAL LOCAL-AGENCY I1 STATE-AGENCY <br /> f7 ay,4an- 0 CORPORATION 0 PARTNERSHIP [] COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME ST�ATE <br /> r ZIP PHONE It WITH AREA CODE <br /> DQ W <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to irbkate ED I SELF-INSURED 0 2 GUARANTEE [:] 3 INSURANCE Q 4 SURETY BOND [::)5 LETTER OF CREDIT E:I 6 EXEMPTION L-3 T STATE FUND <br /> El B STATE RIND&CHIEF FINANCIAL OFFICER LETTER [:19 STATE RIND&CERTIFICATE OF DEPOSIT E::] 10 LOCAL GOVT,MECHANISM 0 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.❑ II.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTFUDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY If JURISDICTION# FACILITY It <br /> 3 ® 6 -70 1Fr <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> © Z3•� � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR(GSTORAGE TANK REGULATIONS <br />