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STATE OF CALIFORNIA `Os <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o YJ o' <br /> ry, <br /> - COMPLETE THIS FORM FORE EACH FACILITY/SITE <br /> MARK ONLY [�JrNEW PERMIT 3 RENEWAL FERMI 5 CHA OF INFORMATION a 7 PE ENTL <br /> ONE REM [� 2 INTERIM PERMIT O a AMENDED PERMIT MPORARY SITE CLOSURE <br /> I. FACT YISI RMATION& ADDRESS-(MUST BE COMPLETED) i <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PAACELa(OPTIOW <br /> )24 <br /> CITY NAME STATEZIP SITE PHONE S WITH AREA CODE <br /> Box CA <br /> TO INDICATE p CORPORATION p l DIVIDUAL p PARTNERSHIP p LOCAL-AGENCY p COUNTY.AGENCY p STATE-AGENcY p FEDERAL.AGENcY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1p T GAS STATION Q 2 DISTRIBUTOR p ,/ IF INDIAN A OF TANKS AT sas E.P.A. L D.a(cpimmij <br /> RESERVATION <br /> Q 3 FARM Q < PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME T.FIRST) PHONE a WITH AREA CODE DAYS: NAME(UST,FIRST) <br /> NIGHTS: NAME(LAST, mnp <br /> FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Ow 0iM1e9M p INDIVIDUAL p LOCAL AGENCY p STATE-AGENCY <br /> p CORPORATION p PARTNERSHIP p CDUNTV-AGENCY p FEDEMLAGEH Y <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ InN bNicaw p INDIVIDUAL p LOCAL-AGENCY p STATE AGENCY <br /> p CORPORATION p PARTNERSHIP p CGUNTY-AGENCY p FEDERAL#GENCV <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 it questions arise. - y/) <br /> TY(TK) HQ 4 4 /V0I— <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY• (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED FA-Lc <br /> ✓ m�binCiale �� 1 SELF INSURED Q 2 GUARANTEE 0 3 INSURANCE p a SURETY BOND <br /> 5 LETTEROFCREOT p 6 EXEMPTION f5 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.= it.a III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF A&KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 6 SIGNATURE) APPLICANT'S TITLE DATE MONTWOAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> couNrvx ^ /] � I ' JuaISpICTpNX FOCI® <br /> LOCATION CODE -OPTIONAL CENSUS TRACTj�TaoAIAr. SUPVISOR-DISTRICT CODE -OPnOMAL <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 /> FORM A(5-91) <br /> //Fp�i/0 MA7 5 <br />