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STATE OF CALIFORNIA ° <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD 3 ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION , FORM A de <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SI�� <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA 0 ILITY NAMr NAME OF OPERATOR <br /> ADDR S (/nL /J <br /> NEAR,5XTCROSSPTREET PARCEL#(OPTIONAL) <br /> CITY NAM STA E ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA52- 8/ <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR = RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 4 PROCESSOR = 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 /> PHONE#WITH AREA CODF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME W <br /> CARE F ESS.NFORJvt;TIONA. <br /> MAILIN R STREETA R S �D ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY N E STAT ZIP OD 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 ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> (]CORPORATION PARTNERSHIP COUNTY-AGENCY 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) HO _4 4 - Q <br /> V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT 0 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.❑ II.❑ 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) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 64W JURISDICTION# FACILITY# <br /> 33 <br /> LOCATION CODE -O TIONAL CENSUS TRACT ; T10�4L SUPVISOR-DIST3JCT� y -OPTIONAL <br /> ( THIS FORM MUST BE ACCOMPANIED BY AT LLEASST(1)OR MORE PERMIT APPLICATION- FORM BB,,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br /> 1� <br />