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1 • • 'G60JaCn CO <br /> STATE OF CALIFORNIA <. i <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH. ILRY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION I :] 7 PERMANENTLY CLOSEQ­=" <br /> ONE ITEM `❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE E4� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACT NAME NAMEOFOPERATOR <br /> -T(- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> kA- <br /> CIIYNAMI, STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> I/ Box <br /> TOINDBC TE D CORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplimaQ <br /> RESERVATION 1 <br /> ❑ 3 FARM ❑ 4 PROCESSOR OR 5 OTHER 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: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) WITH APPA QQnP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILIN ORSTREET'���QjD RE ✓ box b Indicate 7) INDIVIDUAL O LOCAL =1STATE-AGENCY <br /> _ # /�J DO <br /> PARTNERSHIP COUNrYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME r+ T ZIP 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• ✓ boxbiMicale INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY <br /> _ =CORPORATION O PARTNERSHIP 0 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) HQ L4-L4]-E1]:]= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hoz b indicate I SELF INSURED 2 GUARANrEE L_] 3 INSURANCE O 4 SURETYBOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION = 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: 1.❑ 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 NAME(PRINTED&SIGNATURE) APPLICANTS TITLE 4DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY � <br /> COUNTY# JURISDICTION# # <br /> Z�J S 3 <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT# -OP NAL SUPVISOR-DISTRICT CODE -O ��. <br /> t <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLES9 THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> Neu�l�, a>,'scov'ere�CLCS7`= t�ler.�s..e,3,`/� � la aQ-9a-�33A� <br />