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0 Pt'O.1c!'e C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 41 ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYIaL2SD,SI <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE -7, <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME� STATE ZIPS ESITE PHONE If WITH AREA CODE <br /> ✓BOX CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> ' <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 1 GAS STATION 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.If(optional) <br /> 3 FARM a 4 PROCESSOR Q S OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIR40 PH NE#WITH REA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 7/'ZA5-�,✓q L��G- =CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE#IqITH AREA fODE <br /> Z'4,46:1 1 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> az- �� / /� CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY A E STATE ZIP CODE PHONE If WITH AREA CODE <br /> -70 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED =2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE RIND&CERTIFICATE OF DEPOSIT 0 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: 1.❑ 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&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# -7�� <br /> sil F77-1 124 <br /> LOCATION ` <br /> ON CODE -OPTIONAL CENSUUSS TTRA/��C'T# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ®v 'ja 3fl <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(6-95) OWNER MUST FILE THIS FORISM <br /> THE LOCAL AGENCY IMPLEMENTING THE UNDERGR•STORAGE TANK REGULATIONS <br />