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. ' • � eyoua � co <br /> STATE OF CALIFORNIA r i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> o .;. <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLO <br /> ONE ITEM 0 2 INTERIM PERMIT O 4 AMENDED PERMIT b TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSAO FACT TY AME Z7jj C NAME OF OPERATOR <br /> J:t <br /> ADD ESS NEAREST CROSS STREET PARCEL#(OWIONAL) <br /> I <br /> CITY NAME /y / G STACA TE ZIP CODE SITE PHONE#WITH AREA CODE <br /> OC S <br /> ✓ aox '— <br /> TO INDICATE 0 CORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY ED COUNTY-AGENCY Q STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS It AT SITE E.P.A. 1.D.#(optimal) <br /> ATION <br /> RESERV <br /> Q 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSRN (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P NE#WITH AREA CODE DAVS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHON #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) ��WIIH AREA CODE <br /> II. PROPERTY OWNER INFORMATION•(MUST\8t COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION ED PARTNERSHIP = COUNTYAGENCY O 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 ✓box Wndlcate = INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME DE <br /> TATE ZIP CODE <br /> PHONE <br /> AR EAC F <br /> DE <br /> IV, BOARD OF EQUALIZATIONUST <br /> STORAGE FEE ACCOUNT NUMBE -Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 0 indicate O 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> O 4 SURETY BOND <br /> O 5 LETTER OF CREDIT b EXEMPTION 99 OTHER <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.r_1 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(PR IN TED&S IGNATURE) APPLICANTS TITLE DATE MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY At <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OP NAL 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 ON <br /> FORM A(5-91) <br /> F 3A-5 <br /> J <br />