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o -t� <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD #� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> a <br /> • C+ _.N NII'. <br /> COMPLETE THIS FORM FOR EAC CILffYISITE _ <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION El 7 PE ANENTLY CLOSED SITE <br /> ONE ITEM +� 2 INTERIM PERMIT a AMENCED PERMIT 6 TEMPORARY SITE CLOSURE L <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) JC <br /> I}$AOR FACILITY NAME NAME OF OPERATOR <br /> r <br /> ADDRESS I <br /> �7 `J NEAREST CRCSS STREET PARCEL 0( NALy _ <br /> CITY NAME <br /> M:701P CODE SITE PHONE#WiTH AREA CODE <br /> TOINDICATE CORPORATION ED INDIVIDUAL ® PARTNERSHIP [] LOCAL-AGENCY E71 COUNTY-AGENCY STATE-AGENCY <br /> [] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 OAS STATION = 2 DISTRIBUTOR = ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 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 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 S TR EET ADD RESS ✓ box Ioinkale [] INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COOS _______TPHONE#WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ WxtoindicaW INDIVIDUAL 0 LOCAL-AGENCY [] STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP © 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) <br /> rise.TY(TK) HQ 4 4 - a�� / y <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> LLb,,bindca:e 0 I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT =6 EXEMPTION LE 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b -I or Il is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.ED Itl.a <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 B SIGNATURE) APPLICANT'S TITLE DATE MONTHJDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED SY AT LEAST(i)OR MORE PERMIT APPLICATION- FORM 8, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FO RM A(5-91 y <br /> FORt3U37A-5 <br /> { P� <br />