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0 <br /> SOUR e <br /> e <br /> STATE OF CALIFORNIA �P P - <br /> STATE WATER RESOURCES CONTROL BOARD °a <br /> UNDERGROUND STORAGE TANK PER <br /> PLICATION - FORM A <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> MARK ONLY F-11 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SI <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O I NA ,j ( / NAME OF OPERATOR <br /> ADDRE S��� NEA ETC QSSSTREET PARCEL#(OPTIONAL) <br /> W . /* <br /> CITY N STATE l/ P CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ Box <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR Q ,/ IF INDIAN #OF TANS T SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 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 REA COI <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N V <br /> ER ///� /��/J CARE OF ADDRESS FORMA IONLV�PM (5m <br /> y► <br /> ,o OR STREET ADD SS N" YWC �I �ate �,/ GGL�C� �I/ <br /> � Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> NAME ST�1T� � ZIP �� PHONE#WITH AREA CODE <br /> 301 r <br /> IV.BOARD OF EQU LIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 44 - <br /> V. PETROLEUM UST FINANCIA ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 0 SURETY BOND',&j <br /> 5 LETTEROFCREDIT Q 6 EXEMPTION Q 99 OTHER AM <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checkedAjOr <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11. 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/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 06�1- 3� <br /> LOCATION C E -OPTIONAL CENSUS TRA T# -OPTI SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2 i L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMAT <br /> FORM A(5-91) FOR0033A-5 <br />