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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i°dam n <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE m ° <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOV.A 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 OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 60 <br /> CITY NAME STATE IF CODE SITE PHONE#WITH AREA CODE <br /> G�4CA <br /> ✓BOX C71 CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTYAGENCY' STATE-AGENCY' = FEDERAL-AGENCY' <br /> TOINDICATE DISTRICTS <br /> 'Ha rof UST a ptblo apq,complete the foWwing:nemeofsoperAwroltl'wsnn,sedlonorolHawhihi rotes Ne UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORO ✓IF INDIAN #OFTANKS AT SITE E.P.A. I.D.#(o Wnel) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) _7NE#WITH AREA CODE / DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) /' PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> iJ— <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> '577)-25 <br /> MAIDNG Ofl STREET ADDRESS ✓ bmto in&ate INDIVIDUAL OLOCA.-AGENCY OSTATE-AGENCY <br /> GU � f� T 0 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN NAMESTATE ZIP CODE P ONE 0TH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER — CARE OF ADDRESS INFORMATION <br /> n <br /> MAILINGORSTREET ADDRESS -� ✓ boxto Fdrate OINDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> �' Q CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NM6 STATE ZIP CODE _ PHONE p WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to incrmW I SELF-INSURED O 2 GUARANTEE l=3 INSURANCE O 4 SURETYBONO Q 5 LETmROFCREDrr [_j 8 EXEMPTION l= 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =19 STATE FUND&CERTIFICATE OF DEPOSIT l= 10 LOCAL GOVT.MECHANISM = 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 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 /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNERS TITLE DATE MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LEI a= <br /> LOCATION CODE -OPTIONAL CENSUSTRACTp -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(6-95) OWNER MUST FILE THIS FOR#H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRW STORAGE TANK REGULATIONS <br />