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• STATE OF CALIFORNIA • �'2� Y`i <br /> STATE WATER RESOURCES CONTROL BOARD i� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A v a <br /> id'+ . <br /> 400�r.n <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 3 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA RFACILITY NAME NAMEOFOPERATOR <br /> r C. a <br /> ADREST CROSS STREET PARCEL#(OPTIONAL) <br /> S� ) <br /> afrw D-1-. <br /> CITY NA E�� ZIP CO 5��STATE TE PHONE#WITH AREA CODE <br /> 4X09 v Box <br /> '��i32G3� <br /> TOINpC TE Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a 3 GAS STATION 0 2 DISTRIBUTORO '/ IF INDIAN I*OF TANL(S AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION / <br /> Q 3 FARM Q 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 DAVS: NAME(L AST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOE NIGHTS: NAME(LAST,FIRST) N WITH AREA mnp <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ boa 0indkato Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q 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 OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boi0 wKato Q INDIVIDUAL Q LOCAL-AGENCY ❑ STATE AGENCY <br /> ❑CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY ❑ 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 - Q 2 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOO(S) USED <br /> ✓ box 0indkato Q 1 SELF-INSURED Q 2 GUARANTEE ❑ SURANCE ❑4 SURETY BOND <br /> a 5 LETrEROFCREDIT Q&EXEMPTION CV99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless*l or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Y 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) APPLICANT'S TITLE TWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COLINTY# P(141 JURISDICTION M AGILITY# P � <br /> - 8 C <br /> LOCATION CO 710NAC CENSUS TRACT# - TIONAC SUPVISOR•DISTRICT CODE <br /> 23 .80 1 3;?—/ <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. 0 ' <br /> FORM A(5.91) <br /> FOR00333AA.5 <br />