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• e500. e3 <br /> STATE OF CALIFORNIA a CO <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD W , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A yn <br /> •C4(IFOft N,r <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT IV5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE 98 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O ACJ)-ITY NAME NAME OF OPERATOR <br /> ADDR€S O /ile, NE 7CRn�REET, � PARCEL#(OPTIONAL) <br /> Z-VCITY ME STATE/ ZIPTE <br /> SITJ <br /> 7E PHE#WI H AREA CODE <br /> '07 CA <br /> I/ BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORR SER INDIAN <br /> #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 1/(///� <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 CODP <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> VME CARE OF ADDRESS INFORMATION <br /> r du-��5DRESS ✓box to indicate 0INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> Q =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP C DE PHONE#WITH AREA CODE <br /> 2.3 10 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toindicate 0 INDIVIDUAL <br /> LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP 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 -[o I d p 1510 (p <br /> V. PETROLEUM UST FINANCX RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate EY 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE 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 i hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 It.v III.El <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# &7r1P JURISDICTION# FACILITY# <br /> 31T —mss Z9 <br /> LOCATION CODE -01 OPTIONAL CENSU SUPVISOR-gjSTRICT CODE -OPTIONAL ry <br /> THIS FORM MUST BE ACCOMPANIED BY AT L A57(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />