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0 • e°°One son <br /> STATE OF CALIFORNIA <br /> i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANE E <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE S� <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI NATE NAME OF OPER R <br /> ADDRESS NEAREST ROSS 7REET� PARCEL#(OPTIONAL) <br /> CITY NAME / STATE ZIP CODE SITE PHONE#WITH AREA COOE <br /> Lays/d CA $33 t� 8 - Z <br /> ✓ BOX CORPORATION f� INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY (] STATE AGENCY D FEDERAL AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORqV IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(Wlimal) <br /> 3 FARM Q 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) <br /> NIL 8' 75y/ E. <br /> NIGHTS: NAME(LAST,FAST) #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PhIQUE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME /7 /J CARE OF ADDRESS INFORMATION <br /> �1 S �r <br /> MAILINGOR TREETADORES ✓ box WWII a INDIVIDUAL = LOCAL-AGENCY =STAT AGENCY <br /> M CORPORATION 0 PARTNERSHIP = COUNTY AGENCY I= FEDE AL-AGENCY <br /> CITY NAM/ME �O STATE ZIP CODE 3v PHONE#WITH AREA CODE <br /> t �i53 <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Wicale INDIVIDUAL D LOC Mf I� STAT AGENCY <br /> D CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY = FEDE L-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ 0°z blMiwle = 1 SELF INSURED [�]2 GUARANTEE 3 INSURANCE O 4 SUR BOND <br /> E:]5 LETTEROFCREDIT = 6 EXEMPTION O 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 checkei I. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSNAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 1oDAo 16 <br /> fflll = -z�- KO o G S 7 <br /> LOCATION CODE .OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> *3_Z6 ® ' <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATI ON ONLY. <br /> FORM A(5.91) FOR0033A 5 <br />