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'4ga,s� Cq C <br /> STATE OF CALIFORNIA <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ' Cil 1pgp N,R <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY <br /> il <br /> NEW PERMIT 77 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SrrF- <br /> ONE ITEM INTERIM PERMIT a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 0 <br /> 1. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA ACILITY NAM i NAVIt F OPERATOR may— rt„jj <br /> </ <br /> AD ES _ <br /> NEA E-T CROSS TRE`T PARCELs(OPTIO <br /> CI A STATE ZIP E SITE PHONE s WITH AR�C=-= <br /> } CAG <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY [] FEDERAL-AGENCY <br /> DLSTR1CTS <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.s(0PJkv1W) <br /> RESERVATION <br /> 3 FARM '1 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> WITH AREA Cfinr <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> p-rNF a VVffH <br /> It. PROPERTY OWNER INFORMATION MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING OR STREET ADDRESS �-� /1 box mindica>a �,i INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP a COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME d STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> / NAME OF OWN& ` CARE OF ADDRESS INFORMATION <br /> G� MAILING OR STREET ADDRESS <br /> ✓ Dox to INDIVIDUAL LOCAL.AGENCY STATE-AGENCY <br /> r (fib GRPGRATION 77 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> ' S ATT+E �ZIIPPjCOD/}E�+ / PHONE s-WITH CODE <br /> CITY NAME <br /> !�_'l �vr!a- <br /> IV. BOARD OF EQUALIZATION UISJT`lSTORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ '4 4 I- aQ � Q '_ 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> SELF-INSURED _ 2 GUARANTEE 7 INSURANCE d 4 SURETY BOND <br /> ✓ boa toindlcate — <br /> L_.� 5 LETTEROFCREDIT 6=XEMPTION �; 94 OTHER <br /> Vi. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOx INDIGAT6NG WHICH ABOVE ADDRESS SHOULD RE USED FOR LEGAL NOTkF CATIONS ANIS BVULING: 1,Q IL❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S`NAME(PR[NTe'D&SIGNATURE! APPLICANT'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a , JURISDICTION T FACILITY# <br /> Lm <br /> LOCATION CODE -,PrIONAL �SSus RAC 4 _,P :: '•a+= 5 .VISOR-DIS ECT ODE -OPTdOMAt" <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MCRE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORTA A,!L 91, FILETHIS FORM WITH THE LOCAs_AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIO <br /> is 0 <br /> NS FGRo��3A-Rs <br />