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0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE is <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOS <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF CILITY NAME NAME OF OPERATOR <br /> ADDRESS ESTATE <br /> EAREST OB BEET PARCEL#(OPTIONAL) <br /> �A 'OA. <br /> CITY NAM ST CA ZIPTE PHO E N WIREA CODE <br /> 2 I t J! <br /> ✓Box 0 CORPORATION I] INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> N owner of UST B a public agency,=plele the fo!bwng:nam otsmrAorddWion,s iDnorofraw diopomtesihe UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN #OFTANKS AT SITE E.P.A. I.D.It(optional) <br /> RESERVATION 1� <br /> Q 3 FARM 0 4 PROCESSOR EZ05 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(IfAST.FIRST) PHON WWI�TH�AR CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r�r�L'�hZav <br /> NIGHTS: NAME(LAST,FIR" #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILIN�91R STREET ADDRESS � ✓ �xla L-dm" Q INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> / - G. 6o z— CORPORATION O PARTNERSHIP Q UMY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE# ITH AREA CODE <br /> .r..�1 -re 01 9 0X36 z� ��� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFO NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Q �J 61boxto inNpte Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> f O• ( 3 Q CORPORATIONN PARTNERSHIP COUNTY-AGENCY <br /> /C FEDERAL-AGENCY <br /> CI��AM;� � STATE CI Yo0 7C? Z PHONO��ITH O�E7 ODE <br /> /IV. BOARD OF EdUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓W.to Weale = 1 SELF-INSURED .GUARANTEE O 3 INSURANCE Q 4 SURETYBOND =5 LETTEROFCREDIT 0 6 EXEMPTION 17 STATE FUND <br /> 0 N STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 8 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O 990THER <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 /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANKOWNER'STITLE DATE MONTHrOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION It FACILITY# 'o— <br /> z / / X3/ <br /> LOCATION CODE -OPTIONAL CE�$#T OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(6-95) OWNER MUST FILE THIS F ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERG9D STORAGE TANK REGULATIONS <br />