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• • a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETETHIS FORM FOR EA FACILITYISITE <br /> MARK ONLY F7 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA DRF C11-31 NAME NAMEOF OPERATOR <br /> Y, x ni 1 <br /> ADDR71f E YM /] NEARES CROSS ST ET RCEL#IOPTIONAQ <br /> CITY NAME K STATE ZIP CODE SITE PHONE O WITH AREA CODE <br /> CAaA 5 0 <br /> I/ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL E] PARTNERSHIP Q LOCAL-AGENCY E::] COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optianall <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) P ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NITTS'. NAME(L ,FIRST) 17HONE 0 WTH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ?JjONF#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE OMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP Q COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boxbindicale INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> =CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMB R-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 G1117 1 Yj 51 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicale O 1 SELF-INSURED O 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> I�5 LETTEROFCREDT Q 6 EXEMPTION W 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: X II.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PR INTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYPIEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIONC -OTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DIS^TRRICT CODE -OPTIONAL <br /> /\ <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) F 00330.-5 <br />