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P�60JR :S C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> <�aUN N`a <br /> COMPLETE THIS FORM FORE CILITY/SITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT �r_' <br /> CHANGE OF INFORMATION 7 PERMANENTLY CLOSE SITE <br /> r <br /> ONE ITEM L ] 2 INTERIM PERMIT 4 AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS � /all'd eaqQ( NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 7700 erg14 mtzoxte <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA Fft61-53 <br /> ✓ BOX 01 <br /> TOINDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS J�rt GAS STATION O 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM 0 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 ENIGHT�S: <br /> ST,FIRST) <br /> 7 <br /> NIGHTS: NAME(L S , IRST) PHON H EA CODE AST,FI ST ` 1*3 4 <br /> 6-24 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ( CARE OF ADDRESS INFORMATION / <br /> MAILING RSTREETADDRE ✓ box ID indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> P. 0 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NA E , STATE ZIP CO E PHONE#WITH AREA CODE <br /> C <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) JI <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S a.'� <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL E�:] LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 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 - G D <br /> V. PETROLEUM UST FINANC15 RESPONSIBILITY-(MUST BE COM LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate l SELF-INSURED 0 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> [�:] 5 LETTER OF CREDIT (]6 EXEMPTION 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 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3-3 IT <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DIS ICT COD -OPTIONAL <br /> 5 3 a . <br /> THIS FORM MU§T BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-97) gL FOR0033A-5 <br />