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0 F�pu4Cf5 <br /> STATE OF CALIFORNIA " co <br /> r a <br /> STATE WATER RESOURCES CONTROL BOARD s� Q <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A - <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMTT S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ED 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> (L 'Ex 0=r 3 C <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL <br /> W ,2d. Co <br /> 11:1 /Cld <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓BOX LIQ s.ORPORATION 0 INDIVIDUAL [�:] PARTNERSHIP LOCAL-AGENCY ® COUNTY-AGENCY' (] STATE-AGENCY' ® FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'If owner et UST is a public agency,complete the following:name of supervisor of division,section or office who operates the UST <br /> TYPE OF BUSINESS GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 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 /> �'__c; q! —S'q2 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA Cfl E NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> fu d *A ;-REISSLC'" � I L L 4! <br /> FAAILING OR STRE ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> OCORPORATION PARTNERSHIP [] COUNTY-AGENCY 771FEDERAL4GENCY <br /> CITY NAME STAT ZIP CODE PHONE#WITH AREA CODE <br /> '2011-1-/ -2 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OWNER / CARE OF ADDRESS INFORMATION <br /> G` L <br /> - <br /> MAILING ORSTREET <br /> DDRESS ✓ boxtoindicale = INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> I2 017" rze C�l CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE a PHONE WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4147- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE a 3 INSURANCE 0 4 SURETY BOND I=5 LETTER OF CREDIT 0 6 EXEMPTION 7 STATE FUND <br /> B STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND d CERTIFICATE OF DEPOSIT [__1 10 LOCAL GOVT,MECHANISM ff 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 /> TANK OWNER'S NAME(PRINTED 11 SIGNATURETANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY V <br /> .y <br /> COUNTY# JURISDICTION# FACILITY#000g5 <br /> ❑ a1311 1 r- [EE <br /> LOCATION CODE -OPTIONAL 7 CENSUS TRACT# •OPTIONAL SUPVISDR-DISTRICT CODE -OPTIONAL <br /> 2 jjto <br /> THIS FORM MUST BE ACCOMPANIED BY ATL2SST(1)OR MORE PERMIT APPLICATION- FORM B.UNLESS IS IS A CHANGE OF SITE I FORMATION ONLY. <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />