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.4eo�e ee <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> j UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 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 /> DB R AC ITY NA /i/ 4#—1 D NAME OF OPERATOR <br /> AD ESS �� NE STC SSSTRE PARCEL#(OPTIONAL) <br /> lI/ 1 <br /> CIW11TATE ZIP DE SITE PHONE#WI AR CODE <br /> cKn CA 9- - <br /> TOO INDICATE CORPORATION I�INDIVIDUAL 0 PARTNERSHIP LOCAL-DISTRIAGENCY 0 COUMYAGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN M OF TANI{S AT SITE E.P.A. I.D.A(optional) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME G CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS vvv ✓ boabindIcate D INDIVIDUAL O LOCAL AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNrY AGENCY = FEDERAL-AGENCY <br /> CITY NAME Fr/ STATE ZIP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bm to Indicate INDIVIDUAL O LOCAL AGENCY STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP 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 [41]4 - D 2 5 b Z y <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED <br /> ✓ WX to indicate I SELF INSURED 0 UARAMEE L—I 3 INSURANCE 0 4 SURETY SONO <br /> 5 LETTEROFCREDIT EV6 EXEMPTION =1 99 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.❑ 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 A SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY At JURISDICTION# FACILITY# <br /> LOGATiOyLG DE OPTIONAL I CENSUS AC�T` SUPVISOR <br /> gl,QNAL -DISTRICTC DE 710NAL, <br /> THIS FF/ORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UUNNLE S THIS ISSAA/CHANGE OF SITE INFORMATION ONLY, <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> . 0 ,/• / FOR0033Ag6 <br />