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0 • n<e°on cc <br /> STATE OF CALIFORNIA .a `; <br /> STATE WATER RESOURCES CONTROL BOARD 3 mom! a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ;o Yr , <br /> ry; <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE �Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 0ORFAw7Nn NAMt UFCPERATOR <br /> r je' hW Ex <br /> V U <br /> ADIRNEAREST CROSS STREET PARCEL a(OWIONAO <br /> l5 W <br /> CITY NAME�. / STATEA ZIP CODE (JJ SITE PHONE x WITH AREA CODE <br /> TO INDBox <br /> ICATE 0 CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRIC <br /> TYPE OF BUSINESS T GAS STATION 2 DISTRIBUTOR ❑ RESERVATION V IF INDIAN x OF TANKS�T SITE E.P.A. I.D.x/opliaraq <br /> Q 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMF�/ja /J - (,L�- j��, � CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa blMkaN E:1 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION [::I PARTNERSHIP =COUNIYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE IF WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boa0 mbale INDIVIDUAL [—ILOCAL-AGENCYOSTATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP Q COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x 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 -LCL 2L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boabimkare = I SELF-INSURED Q GUARANTEE O 3 INSURANCE A SURETYBDND <br /> D 5 LETTER OFCREDT a EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent t0 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 NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p _ JURISDICTION# FACILITY# <br /> LOCATION CODE -b 3OPTIONAL CENSUSTRACTx B-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL Vy <br /> 2o <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 /> FORMA(5-91) <br /> FOROMM-5 <br />