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STATE OF CALIFORNIA ; <br /> STATE WATER RESOURCES CONTROL BOARD i�,� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �, <br /> COMPLETE THIS FORM FOR EACH ILITYISITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT EjK5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS _ NEAREST CROSS STREET PARCEL#(OPTONAL) <br /> / 3 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 4S�w Zu 9 -9Yf-P S—/,I- <br /> I/ <br /> —! <br /> ✓ Box CORPORATION 0 INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION Q 2 DISTRIBUTOR / / IF INDIAN RESERVATION #OF TANKS AT SITE E.P.A. I.D.N(options/) <br /> 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS Q <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> n .A 9 - /G u <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> -Sew---p— PHONE#WITH AREA COT <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME :r CARE OF ADDRESS INFORMATION <br /> seey . <br /> MAILING OR STREET ADDRESS box bWM O INDIVIDUAL O LOCAL AGENCY STATE AGENCY <br /> 0 CORPORATION L-3 PARTNERSHIP Q COUNTY-AGENCY 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 ✓ lb4 bindbaw INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 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 r4-74 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bo�wlnakale D 1 SELF-INSURED O 2 GUARANTEENSURANCE O 4 SURETY BOND <br /> 5 LETTER OFCREDIT = 6 EXEMPTION O 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: I.O II.0 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 NAM E(PR IN TED&S IGNATU RE) APPLICANTS TITLE DATE MONTH/OAYYEAR <br /> LOCAL AGENCY USE ONLY 1 /, <br /> COUNTY# JURISDICTION# FACILITY# IO L'i•l. (Gj <br /> F3-F91 / Sd <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> � <br /> � 3 F� 3.2 <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 /> FORM A(S91) � / Fg1W37k5 <br />