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OV-CSS <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CL <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 X PARCEL#(OPTION ) <br /> �� 5u <br /> crrY NAME STATE ZIP CODE f SITE PHONE#WITH AREA CODE <br /> 5^ O CA S ao <br /> ✓BOX CORPORATION 0 INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY E:: S <br /> TO INDICATE DISTRICTS X <br /> TATE-AGENCY' FEDERAL—AGENCY` <br /> If 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 a 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> 3 FARM 0 4 PROCESSORii 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTA SON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FI �' P ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) OHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> Z� oCa <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> \ lJ <br /> MAILING OR STREET ADDRESt box to indicate 0 INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> F' U (]CORPORATION (] PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHON #WITH AREA CODE <br /> 57 0 0 C !a 5 20 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _ C <br /> MAILING OR STREET ADDRE S ✓ box to indicate <br /> INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION Q PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PONE WITH AREA CODE <br /> F3 2.0 - 3100 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4—T4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED =2 GUARANTEE 7rK 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> (�8 STATE FUND&CHIEF FINANCIAL OFFICER L ER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 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. III.❑ <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 8 SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> V Z U\ r= 2 8 <br /> LOCAL AGENCY USE ONLY + <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRC�zACT# -OPj(ONAL SUPVISOR•DISTRICT CODE •OPTIONAL <br /> L��IV� 1 I( <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INF RR ATION ONLY. <br /> OWNER MUST FILE THIS FORM H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU§STORAGE TANK REGULATIONS <br /> FORM A(6-95) 0—,�3 J 9 9IJ,//�,�Qe J <br />