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• 0 STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ID <br /> COMPLETE THIS FORM FOR EACH FACILrfYISITE <br /> MARK ONLY E] NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION E 7 PERMANENTL <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D OR FACILITY M NA F OPERATOR <br /> aan - o/ cx4ca� <br /> AODRE EAREST CROS STREET,^, / PMCELM(oPfX)NAL) <br /> CITY ygME �- STACA1/(�/lA ZIP/CO/�/ kms/ ///1 `��W.J-'SwJ SITE PHONE#WITH AREA CODE <br /> OCAI <br /> I/ BOX <br /> T NGC TE CORPORATION Q INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COOUNNTY/#GGEENCY O STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR0 RESERVATION <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 3 Q 3 FARM = 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> A WITH AREA COOF <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 1 PHONE X WITH APPA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bintlbate Q INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O 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 STREET ADDRESS ✓ box Iointllale ED INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> I�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 NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F41_41- Fz; 441 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bov Wlnbfoaie 01 SELF-INSURED I� GUAMRATEE 3INSURANCE 4SURETY BOND <br /> 5 LETrEROFCREDIT 6 EXEMPTION O 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 04Y+t JURISDICTION It FACILITY It <br /> ® �oLIC' Zy I- I I /I/ . <br /> LOCATION COD OPT/ONAL CENSUS�RACi# -yPOpONAL SUPVI R_DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGENGE O�FOR ION ONLY. <br /> FORM A(5-91) <br /> FOR6o55A-5 <br />