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pe,44N < <br /> STATE OF CALIFORNIA W <br /> 'o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ` COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY 1 N PERMIT ,.: 3 RENEWAL PERMIT CHANGE OF INFORMATION L] ] PERMANENTLY 'SED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA LITYNAME — NAMEOF PERATOR <br /> ADDRESS NEAREST OR SSTREET CEL OPTK)NAq VA'1 <br /> v T#m 6 k <br /> CITY ME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 6 <br /> TOIN BOX 771 CORPORATION D INDIVIDUAL I=PARTNERSHIP LOCAL-AGENCY <br /> DISTRICTS <br /> ENCY �COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RE,/ IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. I.D.%(optional) <br /> Q 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CO ACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> FDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> a WITH AREA MDF <br /> TS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ounkil <br /> II. PROPERTY OWNER IFORMATION- UST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> MAILING OR STREET ADDRESS ✓ box bindkE <br /> aW INDIVIDUAL I� LOCAL-AGENCY STATE <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFO MATION-(MUST BE COMP L TED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> MAILING OR STREET ADDRESS ✓ box 0 WxUx O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUAL12 ATION UST STORAGE FEE ACCOUNT NU ER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 <br /> V. PETROLEUM UST F114ANCIAL RESPONSIBILITY-(MUST BE COMPLE D)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMIxat# 0 1 SELF-INSURED 0 2 GUARANTEE [�] 7 INSURANCE A SURETY BOND <br /> =5 LEITER OF CREDT =6 EXEMPTION ,II N 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 WF ICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III. <br /> THIS FORM HAS BEEN N COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY JURISDICTION# F�FACILITY# <br /> EMEAM <br /> _ W <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DIS RICT CGDE -OPTIONAL <br /> o a3 . <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 0 �3.Ah <br /> Z Y <br /> FORM A(5-91) / /-`� / 3 <br /> ,,/ire a, `ova 0� �� � Lp lJ 1 J <br />