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O VN i <br /> STATE OF CALIFORNIA `Oen <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w "� ve <br /> O,;r o <br /> C��,iONN�N <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SRE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> - <br /> DBAA LITY NAME NAME OF OPERATOR <br /> ADDR NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CI N ce STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> BOX <br /> TO INDICATE D CORPORATION D INDIVIDUAL D PARTNERSHIP D LOCAL-AGENCY COUNTY-AGENCY D STATE-AGENCY D FEDERAL-AGENCY <br /> OSTRICTS <br /> TYPE OF BUSINESS D 1 GAS STATION 2 DISTRIBUTOR RESEIRVATION #OF TANKSAT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM 0 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmbindkala D INDIVIDUAL D LOCAL-AGENCY STATE-AGENCY <br /> D CORPORATION D PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box WicaW D INDIVIDUAL D LOCAL-AGENCY D STATE AGENCY <br /> D CORPORATION D PARTNERSHIP D COUNTY AGENCY D FEDERAL-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 F41 4 -n2 5 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hox bindicaN IJ 1 SELF-INSURED D 2 GUARANTEE L-1 3 INSURANCE D 4 SURETY BOND <br /> D 5 LETrEROFCREDIT D 6 EXEMPTION D 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. <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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# ZETr JURISDICTION# FACILITY# <br /> ® SIDCK / ?, = <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVII R-DISTRICT CODE -OPTIONAL <br /> Z I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION <br /> ✓✓FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIgN ONLY. <br /> FORM A(5-91) FOR0113A S <br />