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STATE OF CALIFORNIA ) Ile eozoo^ e. <br /> STATE WATER RESOURCES CONTROL BOARD oo^ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W"� va <br /> COMPLETE THIS FORM FOR EAC CILITYISITE �" ^"" <br /> MARK ONLY ❑ NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION <br /> ONEITEM ❑ T PERMANENTLY CLOSED SITE <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) h� <br /> DBA OR FACILITY NAME <br /> _ NAME OF OPERATOR <br /> ADDRESS <br /> O NEARESTCROSS STREET PARCEL#IOPTIONAN <br /> CIN NAME <br /> STATE ZIP CODE SITE PHONE x✓ eox WITH AREA CODE <br /> CA 9�� <br /> TOINOICATE D CORPORATION D INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY <br /> DISTRICTS COUNTY-AGENCY0 STATE-AGENCY (] FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN p OF TANKS AT SITE (00mal) <br /> O 3 FARM O 4 PROCESSOR O 5 OTHER OOR TRUST LA RESEVATION <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DSD NAME. IRS�G�/1l�C q�PHON]E#WITH AREA COD <br /> i <br /> L (max+-AJ ��� � DAYS: NAME(LAST,FIRST) <br /> NIGHTS NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> ✓ box bintlioale <br /> y/C INDIVIDUAL E LOCAL-AGENCY I� STATE-AGENCY <br /> CITY NAME LL COflPoRATION PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> GOP-L STATE ZIP CODE PHONE#WITH AREA CODE <br /> 9.`�C�D <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER <br />' ^ CARE OF ADDRESS INFORMATION <br /> ^- <br /> MAILING OR STREET ADDRESS <br /> -2 s.3 v,�,., AV---- <br /> ✓box biMkaW 11 yerxIVIDUAL (] LOCAL AGENCY <br /> /� X�JIC- L�STATE AGENCY <br /> CITY NAME - CORPORATION PARTNERSHIP � COUNTY-AGENCY ED FEDERAL-AGENCY <br /> Gfl STAT I —zZIpE � PHONEi WITH AREA CODE <br /> IV. BOARD OFEQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> r <br /> TY(TK) HQ L4444� Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box la indicate E-1 1 SELF IN 0 2 GUARANTEE (� 7 INSURANCE <br /> L7 5 LETTEROFCREOIT Q 6 EXEMPTION 1:14 SURETY BOND <br /> 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box ochecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I ❑ ❑ III <br /> if. ❑ <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 IPR INTED 8 SIGNATURE) <br /> APPLICANTS TITLE DATEMONTWDAY/VEAq <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> r FACILITY# <br /> L � <br /> LOCATIO CODE �0P7IONAL CENSUSs RACT# .nP TIONAL <br /> Oz_ 3 9jl SUPVISOR-DISTRICT CODE -OPTIONAL �r �E /b l-=- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATIOFORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> 300 <br /> FORM A ItzBll FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO <br /> 0 le /// FORON3A.R6 <br />