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• • Nd40VP [B <br /> O <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ye <br /> C�I,�OPNN <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION LV7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFA ILITYNAME NAME OF OPERATOR <br /> t <br /> ADDRESS NEAREST OSS STREE PARCEL#IOPTIONALI <br /> 1193 A) ftc6_ [/ <br /> CITY AME O STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TO INDICATE l�CORPORATION Q INDIVIDUAL 0 PARTNERSHIP DISTRICTSL-AGENCY 0 COUNTYAGENCY O STATE-AGENCY l� FEDERAL-AGENCY <br /> TYPE OF BUSINESS O r GAS STATION 2 DISTRIBUTOR 0 RESERVATION Is OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR 0/6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTA PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE a WITH AREA GO <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRS T) <br /> 11. PROPERTY OWNER INFORMATIO • MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box biedkaw L—I INDIVIDUAL 0 LOCALAGENCY D STATE-AGENCY <br /> =CORPORATION I7 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION (MUSTECOMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box I,Wicae O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE EE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F41 4 - a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILI -(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box blMkak 0 1 SELF-INSURED l=2 PbfRAKTEE = 3 INSURANCE A SURETY BOND <br /> =5 LETTEROFCREDT E2<EXEMPTION 0 83 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.❑ it.❑ 111. <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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 101011 UET <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT WDE -OPTIONAL <br /> 3, 80 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) FCfl0033A�5 <br /> 0 <br /> 41 <br />