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ySoURces <br /> STATE OF CALIFORNIA P c <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W " '�o <br /> COMPLETE THIS FORM FOR EAC CILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT D 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANEN CLO <br /> ONE ITEM E:1 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I, FACILITY/SITE INFORMATION &ADDRESS. (MUST BE COMPLETED) <br /> DBA OR FACILITY NAME I NAME OF OPERATOR <br /> 1)D <br /> ADDRESS tj <br /> [ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA S-3 6 SI-1--777 <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL P RTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY (] STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN # ANKS AT ITE E.P.A. I.D.#(opticnal) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY C PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE a WITH AREA GQDE _ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH BEA CODF <br /> Il, PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> (]CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE is WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 4 4 — Q5;F0 141 <br /> V. PETROLEUM UST FINANCI L RESPONSIBILITY- (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> (�5 LETTER OF CREDIT (]6 EXEMPTION 0 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.D II.F-1 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 NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTHIDAYNEAR <br /> � 7— <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# � 5115111" <br /> Z JURISDICTION# FACILITY# <br /> ifoar Q <br /> LOCATION CODE -OPTIONAk CENSUS TRACT A -OPTI®AL SUPVIS R-DIST ICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION•UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) /� FOR0033A-5 <br />