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oun e <br /> STATE OF CALIFORNIA c `moi <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �` <br /> \�c " <br /> C�(,rONN�� <br /> COMPLETE THIS FORM FOR EACH LITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS r(MUST BE COMPLETED) <br /> DBAOR FACILIJY/NAME � yy NAMEOFOPERATOR <br /> V 7✓ / J Y— <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> Cp G C_ <br /> CITY NAMESTATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> C/ CA <br /> ✓ Box <br /> TOINDICATE (]CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP Q LONCY O COUNTY AGENCY Q STATE AGENCY <br /> DISTRICTS FEDERAL DISTRICTS <br /> TYPE OF BUSINESS F7 1 GAS STATION 0 2 DISTRIBUTOR I O ✓ IF INDIAN M OF T AT SITE E.P.A. I.D.4(optimal) <br /> O 3 FARM O 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUSTLANDS <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 OORRSTREET ADDRESS T ✓hox bintlicate D INDIVIDUAL (] LOCpL-AGENCY EDSTATE-AGENCY <br /> (/ hop 1 I]CORPORATION = PARTNERSHIP E71COUNTYAGENCY I� FEDERAL-AGENCY <br /> CITY NAME •/ -' STATE. ZIP CODE PHONE#WITH AREA CODE <br /> S c CCr <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAMEOF WNER CARE OLIJRESS INFORMATIO <br /> MAIL( RSTREET ADDRESS 157 C ✓ box Wmicate INDIVIDUAL LOCAL-AGENCY 0 STATE AGENCY <br /> �J O CORPORATION O PARTNERSHIP COUNTY-AGENCY E= FEDERAL-AGENCY <br /> CITU N STgJE� ZIP C E ��� PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST S ORAGE FEE ACCOUNT NUMBER r Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-141- a 7, <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindbaW Q 1 SELF-INSURED 0 2 GUARANTEE7JNSURANCE <br /> ,L�/ I�d SURETY BOND <br /> D 5 LET Efl OF CREDIT 6 EXEMPTION 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.0 III. <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED851GNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS,: T# -OPT_ IOQLAL SUPVIS DR-DISTRICT CODES -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION r FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> 'A-0—/�'�' ?19& <br /> 19& FORONJA5 <br />