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! • �6au- e <br /> STATE OF CALIFORNIA <br /> h STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> [— <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE 9 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Ba_i> <br /> ADD S - NEAREST CROSS STREET PARCEL p(OPfIONAL) <br /> 0 <br /> CITY NAME STATE EZIP SITE PHONE#,WITH AREA CODE <br /> ✓ BOX <br /> TO INDICATE COR ATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> rPE67 S 1 GAS STATION 2 DISTRIBUTOR0 ✓ IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYNAME LAST,.I T) PHONE#WITH AR CODE_ f DAYS: NAME(LAST, <br /> ,45r -VAKV, Zorn) <br /> NIGHTS: NAME(LAST, RST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST)/� !_ I`�1ljc,T,`b Z47�/ <br /> ct —?j /i `(� J o <br /> PHONE#WITH <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILIINTG OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> 0- r ORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEI `�� PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) G/`!6L` <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box ale 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> Z <br /> CI NAME � STATE IP CODE <br /> _ H/E j"R AREA CODEG� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. Z G!7 <br /> TY(TK) HQ 4 4 - b Z 6 <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION = 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.[:] II.O 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 /> �4 __Ft� 0 101 ) I eme/R-43 <br /> LOCATION CODE -OPTIONAL CENSUSRACT -OPTIONAL SUPVISOR_DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) FOR0033A-5 <br /> ��� <br />