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, <br /> STATE OF CALIFORNIA .e <br /> STATE WATER RESOURCES CONTROL BOARD ; '�, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A °�� " �; <br /> `: o <br /> t( l' C4IIOPNn <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 5 <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF CILIN NAME OF OPERATOR <br /> Cerr ) <br /> ADDRESS . NEAREST CROSS STREET PARCEL N(OPrIONAQ <br /> CITY NAME STATE ZIP DE SITE PHON TH AREA CODE <br /> 11/-59EXfo CA �a oq t <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY Q STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> [NIGHTS: <br /> E(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE 9 WITH AREA CODE <br /> AME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box biMkats O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> I�CORPORATION PARTNERSHIP O COUNTY-AGENCY E:] FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> R,Q <br /> MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL 0 LOCAL-AGENCY Q STATE AGENCY <br /> =CORPORATION O PARTNERSHIP D COUNTY AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 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 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ boll bindkate = 1 SELF INSURED =2 GUARANTEE O 3 INSURANCE =4 SURETY BOND <br /> E=1 5 LETTER OF CREDIT li<6 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: L II.0 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 a SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY C L121— <br /> C�OUNTY# JURISDICTION# FACILITY# <br /> M <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 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 INFORMA�ON ONLY. <br /> FORM A(5-91) / O' n � I(� FORS <br />