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STATE OF CALIFORNIA <br /> °�s.0-c.s 2 <br /> STATE WATER RESOURCES CONTROL BOARD :' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A � "' <br /> L <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERM/HGENTLY CLOSED SITE <br /> ONE ITEM J 2 INTERIM PERMIT C 4 AMENOEO PERMIT E] & TEMPORARY SITE CLOSURE Ccs�- <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) t— ' <br /> DBA OR FACILITY NAmn / NAME OF OFF RAT <br /> ADDRESS NEAREST C OSS STREET PARC ZONAL) <br /> elrY NAME - <br /> f STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> v' i7 TCC` CA `� 3G ?,�S ? <br /> BOX --�) - -3/// <br /> TO INDICATE -CORPORATION 0 INDIVIDUAL PARTNERSHIP Q LOCAt-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM O 4 PROCESSOR 5 OTHER 0 RESERVATION <br /> OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME tLAST,F6RST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> I cT Y T i+, T—rc�P � 1 7 <br /> ONES WITH ARrA r0r)F <br /> NIGHTS: NAME(LAST,FIRST) 1 PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHQNF x WIT <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR$TREE`T ADDRESS ✓ box to indicate Q INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> '� I ( / CJ7-5 f =CORPORATION (= PARTNERSHIP COUNTY-AGENCY <br /> Q FEDERAL-AGENCY <br /> CITY NAME „ STA ZIP CODE PHONE#WITH AREA CODE <br /> 111, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> c.' <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL [] STATE-AGENCY <br /> INDIVIDUAL =J LOCAL-AGENCY <br /> [I]CORPORATION p PARTNERSHIP 0 COUNTY-AGENCY CI FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Calf(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 /> ✓ bow to indicate 1 SELF INSURED Q 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> F7 5 LETTER OF CREDIT Q d EXEMPTION 99 OTHER <br /> Vl. 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 A80VE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II. Ill.= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# /f� <br /> EE <br /> LOCATION CODE -OPr1ONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ) L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FOAM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FOR0033A-5 <br /> i <br /> L— _ <br />