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STATE OF CALIFORNIA _ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F--j 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACIIJZo NAME er a a b NAME OF OPERATOR <br /> ADDBESSiN^C/•, lVl� I lar -5�� NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITU NAC/•M$ STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> Box <br /> TOINDICATE CORPORATION O INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN 4 OF TAHy{5 AT SITE E.P.A. I.D.#/optimal) <br /> 3 FARM O 4 PROCESSOR 5 OTHER O RESERVATION �;f{ <br /> O 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 /> 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 OR STREET ADDRESS ` boa 0MkM 0INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY I] FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IN:WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STIR ADDRESS ✓boa binOKaN Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O CORPORATION = PARTNERSHIP Q COUNrY#GENCY Q FEDERAL AGENCY <br /> CITY NAME 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 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED / <br /> ✓boa biWwaN 0 1 SELF-INSURED O 2 GUARANTEE O ]INSURANCE <br /> O 5 LETTEROFCREOIT O 6 EXEMPTION93 OTHER O 4 SURETY BOND <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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION# FACILITY# <br /> ® 4466;q 12- <br /> LOCATION QQQE -OPT/ONAL CENSUS jBACT# -ppTfQNAL SUPVISOR-DISTRICT YOE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORcM—li,UUNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY <br /> FORM A(6-91) <br /> q FOR <br /> 3 z <br /> _•. <br />