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'souRCC3 <br /> STATE OF CALIFORNIA he^ roti <br /> STATE WATER RESOURCES CONTROL BOARD , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM A <br /> - <br /> s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> I <br /> CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX ORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY° 0 STATE-AGENCY° FEDERAL-AGENCY° <br /> TO INDICATE DISTRICTS <br /> N owner of UST is a public agency,complete the following name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE I E.P.A. 1.D.If(optional) <br /> 40 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) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY ®STATE-AGENCY <br /> ORPORATION PARTNERSHIP ®COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PH NE#WITH AREA CODE <br /> d <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME QF OWNER CARE OF ADDRESS INFORMATION <br /> aC <br /> MAILING OR STREET ADDRESS ✓ box to indicate ®INDIVIDUAL LOCAL-AGENCY a STATE-AGENCY <br /> r Y CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ST TE ZIPCODE 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 M44- -101'51 40 7t�M <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> 11 <br /> ✓box to indicate 9 SELF-INSURED =2 GUARANTEE ®3 INSURANCE 0 4 SURETY BOND Q 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 90 LOCAL GOVT.MECHANISM O 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.❑ It.❑ 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) NK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> '1411 T92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL =US TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT#11)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORTHE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />