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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE in <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE IC Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) JJ <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS - NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> E.LoUK� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> i'�0 nC�PC� CA <br /> ✓ BOX E3 CORPORATION O INDIVIDUAL E:3 PARTNERSHIP O LOCAL-AGENCY ED COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> M ownerof UST¢a P&Ic ap rq,mmgbte the f0ownT.name o(sgervisorof clMsim,section or office which operates the UST <br /> TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR Q 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 COMPLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O 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 /> MAILING OR STREET ADDRESS ✓ boxto iMimte Q INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION O PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 9 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -Ll I I I I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxlo inCcate 0 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE O 4 SURETVBOND [:15 LETTEROFCREDIT O 6 EXEMPTION O p STATE FUND <br /> 0 6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER [::19 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM E:1 W 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.❑ it.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It F�ACCIILIIT�Y�# <br /> m FT—T-1 � J <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(6.95) OWNER MUST FILE THIS FOWITH THE LOCAL AGENCY IMPLEMENTING THE UNDER 0NO STORAGE TANK REGULATIONS <br />