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0t 60Va e <br /> STATE OF CALIFORNIA c� <br /> STATE WATER RESOURCES CONTROL BOARD i . <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 5��� 40 <br /> C ORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERM 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED T : <br /> ONE ITEM 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADD SS-(MUST B LETED) <br /> D R FACILITY NAME NAM PER TOp A /� <br /> (m <br /> A 1n?rf (Tl� NEAR T ROSSSSjREE�E_r /'/ PARCEL#(OPTIONAL) <br /> _ 5 i5s10� <br /> CITY M .ejI STATE ZIP SITE PHONE WI R iODE 493 <br /> CA <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTORRESER INDIAN OF TSS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS J1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA F ST) _ PHO E#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> AME(LAST, �/. <br /> GHTS: NAME(LAST,F{RST) PHOKE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH REA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA E CARE OF ADDRESS INFORMATION <br /> MAILIUQ.OR STREET A ESS ✓ box to Indicate 0 INDIVIDUAL LOCAL-AGENCY <br /> ^ - / ` 0 STATE-AGENCY <br /> /* <br /> U X [/ / 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAMST TE CODE PHONE#WITH AREA CODE <br /> i01bl <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMNEP CARE OF ADDRESS INFORMATION <br /> to <br /> -Th <br /> ^'MAIL) ST ET DDRESS _ ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY STATE ZIP E 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 I_4141- 3-1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate _ t SELF-INSURED E] 2 ARANTEE 3 INSURANCE 0 4 SURETYBOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION L] 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: I.F] 11.IV 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# JURISDICTION# FACILITY# <br /> LOCATION CQD -OPTIONAL i CENSUST CS# - TIONAL SUPVISOR- IS R`C COI E -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,I NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(1z-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ft 0 /�'�� / FOR0033A-R6 <br /> Ci0'/ <br />