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• • eisowcea <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> /v �e FYI . o <br /> uonpn <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE,, 4 <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DSAORF CILITYNAME NAMEOFOPERATOR <br /> U e• J)dije" <br /> ADDRESS-5-5(p 0y NEAR`�CROSS� RS� . PARCEL M(OPfpNAU <br /> CITY STATE ZIP DOOE TE PHONE#WITH AREA CODE <br /> NAME <br /> CfCfa7, CA <br /> ✓ BOX <br /> TO INDICATE 0 CORPORATION [::I INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ T GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.0.a(opri0nao <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS O <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 /> PHONE I WITH AS A C111 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa birdkalo INDIVIDUAL 0 LOCALAGENCY (]STATE-AG6ZY <br /> E:1 CORPORATION O PARTNERSHIP 0 COUNTY AGENCY D FEDERAL-AGENCY <br /> CITY NAMESTATE 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 ✓ boa 0 Micat6 O INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> I�CORPORATION O PARTNERSHIP Ij COUNTY-AGENCY O 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 F4747- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boa biMlcale O I SEUNNSURED0 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> f� 5 LETTER OF CREDIT B EXEMPTION Q 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: 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# cvqI4 JURISDICTION# FACILITY# <br /> SY pmw 3S I 1 1213 3 q <br /> LOCATION CODE -OP77ONAL CENSUS TRACT! -OPTI(yJAL SUPVISOR-DISTRICT CODE -OPI&WAIL <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 /> FORMA(5-91) <br /> FOR0033A.5 <br /> 1.8-V K\ 46 4k Z� �\� <br />