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OltO�RCfi <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a �, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A : ` ._ <br /> COMPLETE THIS FORM FOR EACH FA n VISITE <br /> PARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERW<GNTLY CLOSED SITE <br /> 'ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME _ NAME OF OPERATOR <br /> V 1-7n -i, s i.¢G <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> I/ BOX <br /> TO INDICATE CORPORATION Q INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY (Q STATE-AGENCY <br /> DISTRICTS FEDERAL•AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR Q ✓^IF INDIAN #OF TANKS AT SITE E.P.A. L 0.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY C NTACT 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 /> PH �a Ta AR;: c <br /> II. PROPERTY OWNER INRIIORMA I ION• MUST BE COMPLETED <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box birbicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> []CORPORA11ON [] PARTNERSHIP Q COuNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER I CARE OF ADDRESS INFORMATION <br /> t <br /> MAILING OR STREET ADDRESS ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> IQ CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EEUS =LITY <br /> COUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQV. PETROLEUMUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boibind'Kate L� I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE <br /> (,J<SURETY BOND <br /> 5 LETTEROFCREDIT Q 6 EXEMPTION []99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. 11.❑ 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 b SIGNATURE) APPLICANTS TITLE <br /> LOCAL <br /> MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FAC IL`ITY# r/ <br /> C) / (? 7 <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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(5-91) <br /> 1 ! FORoT,3A-5 <br />