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• • "t5°UPCF4 <br /> STATE OF CALIFORNIA p � `o^ <br /> STATE WATER RESOURCES CONTROL BOARD 3 0 <br /> /Y1V/ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�'� '"e <br /> O <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE ����-°""•� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITTE <br /> ONE ITEM ❑ 2 INTERIM PERMIT �I 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ���/// <br /> DBA OR C IT��Y,,N A//ME NAME OF OPERATOR <br /> W� <br /> ADDR S NEAR CF;OSS STREET PARCEL#(OPTONAU <br /> CITY NAM STATE ZIP C E SITE PHONE# TH AREA CODE <br /> ✓ BOX CA � N �/'tl, <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY � COUNTY AGENCY 0 STATE-AGENCY <br /> DISTRICTS O FEDERALAGENCY <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR O S 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) <br /> aunNc w <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CAPE OF ADDRESS INFORMATION <br /> I <br /> MAILING OR STREET ORES ✓Imx blMicale O INDIVIDUAL LOCAL AGENCY STATE AGENCY <br /> VU <br /> CORPORATION = PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CI M STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ Cox min0ica16 L-:] INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY [--jFEDERAL-AGENCYNAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 14L�-FQJZ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE CO LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bMule �J I SELF-INSURED LF 2 GUARANTEE E-1 3 INSURANCE 4 SURELY BOND <br /> CI 5 LETTER OF CREDIT E] 6 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: L IL 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 MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE TIONAL iCENSUS TgACT Nj�71QNA{� SUPVISOR-DISTRICT CODE -OPT/ONAL --- <br /> THIS FOF%MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OIIIYYYNLY, <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> �C p � FOR003i <br />