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- ' 't60JP f4 f0 <br /> STATE OF CALIFORNIA J '^ <br /> e <br /> STATE WATER RESOURCES CONTROL BOARD a ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NACME OF OPpRATOR <br /> ADDRESS ter. NEA STCROSSS REET PARCEL#IOPFIONAu <br /> rDECITY NAME / / / STATE ZIP SITE PHONE WITH AREA CODE <br /> ✓ Box <br /> TO INDICATE [_1 CORPORATION Q INDIVIDUAL ^PARTNERSHIP 0 LOCAL AGENCY E= COUNTY AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ V IF INDIAN R SERVATION #OFT AT SITE E.P.A. I.D.%(optianap <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OFt iTRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAVE N//AME(L ST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) <br /> _ <br /> NIGHT N ME(LAST,FIRST) PHONE% H A A COD NIGH]S: NAME(LAST,FIRST) <br /> PHONE#WITH AREA COD� <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME n ____ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETAD ESS ✓box bIndicate D INDIVIDUAL I= LOCAL-AGENCY O STATE-AGENCY <br /> 1�j3 CORPORATION ]�,PARTNERSHIP =COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME _�� STS ZIP CODE��� PHONE%WITH AREA CODE <br /> -77/ <br /> III. TANK 0 L ER INFORMATION-(MUST BE COMPLETED) L!f T/6 <br /> NAME OF OWN R CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ baxbiMkale INDIVIDUAL O LOCAL-AGENCY (� STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION US,T.STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b intlicale L_1 1 SELF INSURED 0 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT E:j 6 EXEMPTION L7 W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: X II.❑ III.❑ <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&SIGPIATURE) APPLIC TSTITLE DATE MO THIDAY/VEAR <br /> 12-3 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> - - <br /> LOGATIONCODE -OPTIONAL '.CENSUS TRACT -OPTIONAL SUPVISOR DISTRICT CODE -OPTIONAL <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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOI <br />