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i -V14 �I P�yOUP Q CO <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD Wy��,.. Y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,,� <br /> �(��OPP.� <br /> COMPLETE THIS FORM FOR EAC CILtrYISITE <br /> MARK ONLY F 1 NEW PERMIT O 3 RENEWAL PERMIT MARK <br /> CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM D 2 INTERIM PERMIT a 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA RFACILITY NAME NAMEOFOPERATOR <br /> pDDR SS NEA 3T CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE A ZIP CO E SIT^PHONE#WITH AREA CODE <br /> 0_5 <br /> C Is <br /> TOINDCATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNrY-AGENCY Q STATE-AGENCY Q FEDEM4AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR / <br /> IF INDIAN <br /> IS OF T KS AT SITE E.P.A. 1.D.x(optimal) <br /> 3 FARM O 4 PROCESSOR X <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <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 /> If. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box W# Q INDIVIDUAL QLOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COM)%ETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS I/ WX 10iQ INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDEIMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT N%AWECE <br /> )323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -61A q1T 11-7. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CENTIFY THE METHOD(S) USED <br /> ✓ lxy 0md,.I. Q 1 SELF-INSURED Q 2 GUARQ3INSURANQ!SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 E%EMPTION Q Il OTHER <br /> Vt. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.O 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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It <br /> LOCATION C E -OPTIONAL CENSUS TRACT -DPTIO L SUPVISOR-DISTRICT CODE -OPTIONAL <br /> eg 3 . <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATI ONLY. <br /> FORM A(5-91) F 5 <br /> �� <br />