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ggOuw � <br /> STATE OF CALIFORNIA eee ��- <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A y o <br /> COMPLETE THIS FORM FOR EA FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY LOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME INAME OF OPERATOR <br /> 6jky;zL ro 1tvIC6 <br /> ADDRESS C✓ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> t <br /> CITY NAME STATE ZIP CODE SITE PHONES ITH AREA CODE <br /> i CABOX <br /> /` <br /> TOININCATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERAL-AGENCY <br /> DISTRITYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> IF INDIAN <br /> N A OF TANKS AT SITE E.P.A. 1.0.a(omdanW) <br /> O 3 FARM a 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) P41�a :5HO E a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> HONE I WITH AREA r.QnF <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA GOOF I <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box Irdnala a INDIVIDUAL Q LOCAL-AGENCY ED STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bwbiMkM Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION PARTNERSHIP Q COUNrY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a 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 D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hwnWkala Q I SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BONG <br /> O 5 LETTEROFCREDR Q 9 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 <br /> ORRECTAPPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYIYEAR <br /> LOCAL AGENCY USE ONLY l� <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE - TIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2 F0 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS TtVS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOROMM-5 <br />