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'So...C <br /> STATE OF CALIFORNIA .r r . cO� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A as _ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT BZf 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ® 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE OU <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA EA2 NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> n <br /> CITY N E STATECODE HONE#WITH AREA CODE <br /> CAZIP <br /> ✓BOX ORPORATION Q INDIVIDUAL 0 PARTNERSHIP a LOCAL-AGENCY COUNTY-AGENCY° (� STATE-AGENCY° Q FEDERAL-AGENCY° <br /> TO INDICATE DISTRICTS <br /> °M owner of UST is a public agency,complete the following:name of supervisor of division,sedim or office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION ❑ 2 DISTRIBUTORpESEIF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(option/al) <br /> 0 3 FARM 4 PROCESSOR ® 5 OTHER OR TRUST LANDS edL&O <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME( T,FIRST) PHONE#WITH AFIEA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LA FIR PHONE#INITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> 7�o CARE OF ADDRESS INFORMATION <br /> MAILIN R STR ADDRESS ✓ box to indicate =INDIVIDUAL = LOCAL-AGENCY = STATE-AGENCY <br /> it <br /> CORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NA STAT ZIP COD PHONE#WITH REA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM=pE CARE OF ADDRESS INFORMATION <br /> zonme <br /> MAILIN ST ADDRESS ✓ box tolodicate INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP (]COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY N STA ZIP OD PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -j I I I —T <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indkate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE ®4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION a 7 STATE FUND <br /> 6 STATE RIND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 6 CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 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. it. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TAN O 'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MO H1DAY AR <br /> LO AL GENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> v' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FO THE LOCAL AGENCY IMPLEMENTING THE UNDERGR TORAGE TANK REGULATIONS <br />