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0 0 coon e <br /> STATE OF CALIFORNIA �,+ °O+� <br /> STATE WATER RESOURCES CONTROL BOARD m., ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W � �e <br /> '^ ; s.. o <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE zz <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF C ITY NAME OF OPERATOR <br /> ADDR� �� _ NEAREST CROSS STREET PMCELM(OPfIONAy <br /> CITY N ME STATE ZIP C " SITE PHONE#WITH AREA CODE <br /> ✓ Box <br /> TOINDICATE O CORPORATION D INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCY O COUNTY AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ R INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> ❑ 3 FARM ❑ 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) PHONE a WITH AREA C01717 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0 ndkate = INDIVIDUAL 0 LOCAL-AGENCY D STATE-AGENCY <br /> E=j CORPORATION E�j PARTNERSHIP O COUNTY-AGENCY 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 0indkate O INDIVIDUAL 0 LOCAL-AGENCY f� STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION <br /> �UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -101-1 1 1 1 1 1&!L I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box bhbkata I SELF-INSURED [=1 ktUARANTEE [=1 3 INSURANCE =1 4 SURETY BOND <br /> 5 LETrEROPCREDIT LV6 EXEMPTION L-1 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> r5 y <br /> LOCATIONCODE -OP ZONAL CENSUS TRACT# -OP#N6_ SUPVISOR-DISTRICT CODE-OPTIONAL <br /> 23 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A 5 <br /> 0 ��� <br />