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4 0 'eyoVwces <br /> STATE OF CAUFORNIA ^+ P <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE .owe <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5p <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME O� NAME OF OPERATOR <br /> ADDRESS NEARES1 CROSS STREET PARCEL#(OPTIONAL) <br /> CITY STAC6A ZIP CO TEP NE#WITH AREA CODE <br /> TOINDBCATE O CORPORATION F—I INDIVIDUAL l] PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY AGENCY O STATE AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F7 t GAS.STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(mlimal) <br /> RESERVATION pJ <br /> 3 FARM ❑ 4 PROCESSOR = 5 OTHER OR TRUST LANDS 75 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAV (LAST,FIR T) 'APH NE#WITH A EA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST5 NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> C O v/ Z_ <br /> MAILING OR STREET ADDRESS ✓ lrox miMkale I� INDIVIDUAL O LOCAL AGENCY D STATE AGENCY <br /> Q .�Q 0 CORPORATION E�j PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY ME ST ZIP�Do�23 HONE#WITH AREA CODE <br /> CCCii���111111 /q !/iJ`M7 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW NER At CARE OF ADDRESS INFORMATION <br /> MAILI OR STREET ADDRESS ✓ taxmiMicale 0 INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> b- �� / =1 CORPORATION O PARTNERSHIP 0 COUNTY#GENCY E::] FEDERALAGENC <br /> CITY NAME STATFA ZIP CODE lPHONE#WITH AREA CODE <br /> 7- <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4L -n�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box mindkaw — I SELFINSUREO F_2 GUARANTEE URANCE (]4 SURETY BOND <br /> (—I 5 LETTEROFCREDIT (J 6 EXEMPTION kn 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: L[—] II. III, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND C RRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> C <br /> JURISDICTION# FACILjrY# <br /> LOCATIONCODE OPTIONAL CENSUS TRACT# -OPTIONAL I SUPVISOR-OISTRICTCODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE IINNFFO/RMA /N ONLY. <br /> FORM A(I2 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 0 <br /> r""0033A R6 <br />