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• STATE OF CALIFORNIA • •``ooe ` <br /> STATE WATER RESOURCES CONTROL BOARD "P cao <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 PERMANENTLY CLOSE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSAORFACILITVNAME - NAMEOFOPERATOR <br /> '1 <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> � f <br /> Is <br /> CI NAME a G STATE ZIP CODE <br /> SITE PHONE#WITH AREA CODE <br /> / <br /> ✓ eox CA <br /> TO INDICATE O CORPORATION O INDIVIDUAL Q PARTNERSHIP 0 LOCAL AGENCY Q COUNTY AGENCY <br /> DISTRICTS O STATE-AGENCY O FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR5 OTHER ❑ RESERVATION <br /> 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 /> NIGHTS; NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST, IS <br /> If. PROPERTY OWNER INFORMATIgV- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ hox biMbal6 INDIVIDUAL O LOCAL-AGENCY El STATE-AGENCY <br /> ED CORPORATION Q PARTNERSHIP = COUNTY-AGENCY L-1 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 /> MAI LING OR STREET-ADDRESS• ✓box roinOkala O INDIVIDUAL O LOCAL-AGENCY L-1 STATE AGENCY <br /> CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NAME - \ STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE A COUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MU BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box binbkale J I SELF-INSURED E::] 2 GUARANTEE O 3 INSURANCE <br /> 5 LETTER OF CREDIT I SURETY BOND <br /> 6 EXEMPTION _f 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal no !cation 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 OTIFICATIONS AND BILLING: L IL❑ III.❑ <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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY y <br /> COUNTY# JURISDICTION# --FFATC-IILLIITYY It <br /> LOCATION CODE -OPTION (CENSUS TRACT# -OPTIONAL SUPVISOR-DIST TCO E -OPTfONAL <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(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />