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STATE OF CALIFORNIA ``s <br /> STATE WATER RESOURCES CONTROL BOARD '4m. '; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A - � vo <br /> � -YI , o' <br /> COMPLETE THIS FORM FOR EAC ILITY/SITE <br /> MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT O 6 AMENDED PERMIT D 8 TEMPORARY SITE CLOSURE 1a3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> /14 C.,-!k w-- CA <br /> BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNTYAGENCY 0 STATE AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#IcpfiaMl) <br /> RESERVATION <br /> 3 FARM Q 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 CWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bor bir ..W Q INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> D CORPORATION I1 PARTNERSHIP 0 COUNTYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE 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 ✓WX 0INW l# Q INDIVIDUAL LOCAL-AGENCY I] STATE AGENCY <br /> 0 CORPORATION ED PARTNERSHIP COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE LP 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 44 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bo.bvekN O 1 SELF INSURED 0 2 GUARANTEE E] 3 INSURANCE O A SURETY BOND <br /> 5 LETTEROFCRED(T Q 6 EXEMPTION 0 W 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.O IN.Q <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 A SIGNATURE) APPLICANTS TITLE DATE MONTH/OAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 4 ( I I IY I U 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z33.j I .31� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) I FOROMM5 <br />