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STATE OF CALIFORNIA ,^ " <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY u 1 NEW PERMIT 0 3 RENEWAL PERMITCHANGE OF INFORMATION O 7 PERMANENTL <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OF OCERATOR <br /> 4 r �c1 ifx / <br /> ADDRESS NEARESTCROSS BT EET PARCEIM(OPTIONAU <br /> S3 �l•� <br /> CITY NAME STATE ZIP CODE SITE PHONE AREA CODE <br /> e4o CA Q7!5 <br /> ✓ BOX CORPORATION Q INDIVIDUAL PARTNERSHIP D LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TOINDICATE DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR RE,/ IFINDIAN <br /> SERVATION NOF TANKS AT SITE E.P.A. I.D.%(optional) <br /> O 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> V-H, <br /> ME(LAST, )RST) PHONE AREA DAYS: NAME(LAST,FIRST) <br /> los to JerPWnNE A WITH AREA CONAME(LAST.FI T) PHONE%WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA C::�d <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 4 /�Ol <br /> MAILING OR STR ADDRESS ,%/ ✓ boxblMbaU 0 INDIVIDUAL 0 LOCALAGENCV O STATE-AGENCY <br /> CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME L STr< ZIP CODE� PHONE%WITH AREA CODE <br /> (moi !lO�SS <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER //�' CARE OF ADDRESS INFORMATION <br /> MAILING OR ST ET ADD ES ✓ box bind'bale INDIVIDUAL O LOCAL-AGENCYQ STATE AGENCY <br /> ih OJ goo ORPORATION PARTNERSHIP COUNTY AGENCY =1 FEDERAL-AGENCY <br /> lJ f 11 STT ZIP CO C �� / PHONE%WITH AREA CODE <br /> CITY NAME <br /> cY/L 1 �� 4 Y .J 6 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlbale 1 SELF INSURED I=2 GUARANTEE 3 INSURANCE O 4 SURETYBOND <br /> =5 LETTEROFCREDT =6 EXEMPTION Q N 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: I. IL 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 NAM E(PH INTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY% JURIS� D�N FACILE <br /> m ILEI--ILS/-I y Icy I.�II <br /> LOCATION CODE -OPTION CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL Z_ <br /> THIS FORM MUST EACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF S�INFOLY s <br /> FORMA 15-911 <br />