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• ecoo. � <br /> STATE OF CALIFORNIA - ` <br /> ti� <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A m� sse <br /> `�I,f ONN,� <br /> COMPLETE THIS FORM FOR EACH CILn-YISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT L_] 6 TEMPORARY SITE CLOSURE y <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) O <br /> DBA OR PLITY NAME p NAME OF OPERATOR <br /> ADDRESS �n / NEAREST CROSS STREET PARCEL#(OPrIONAL) <br /> Y yl <br /> CITU NAME g4'0 <br /> 'O0 STATCEA Z CODE b SI^FORD %WITHA <br /> — <br /> E <br /> ✓ Box <br /> TOINDICATE CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNrY-AGENCY O STATE-AGENCY O FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION O 2 DISTRIBUTOR / O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#rnpfimal) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> O � OR TRUST LANDS <br /> EMERGENCY CONTACT PERS N (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-opilonal <br /> DAYS: NAME(LAST,FIRST) `111NE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE NWITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA C <br /> II. PROPERTY OWNER INFORMATION• MUST BE OMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bintlbale INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> D CORPORATION 0 PARTNERSHIP Q COUNTY AGENCY 0 FEDERAL-AGENCY <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 STREETADDRESS box bbkkal# INDIVIDUAL <br /> O O LOCAL-AGENCY STATE AGENCY <br /> I� PORATION = PARTNERSHIP 0 COUNTY-AGENCY D FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call( 6)323-9555 if questions arise. <br /> TY(TK) HQ F4—T4]- A- <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY•(MUST BE COMPLETED) THE METHOD(S) USED <br /> ✓ box'I, a. I SELFINSURED 0 2 GUARANTEE 3 INSURANCE E:�]4 SURETY BOND <br /> I= 5 LETrEROFCREDIT O 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank Ter unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: .❑ it.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TR AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAVIV'EAR <br /> LOCAL AGENCY USE ONLY PACF Se <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CO DE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISa DI STRICT CO DE -OPTIONAL <br /> 3, <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) <br /> FORW39A5 <br />