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ouAces <br /> STATE OF CALIFORNIA Ar Pts...... cO, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A .� . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION CL <br /> MARK ONLY F-17 PERMANENTLY❑ ❑ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 4<:7] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSSSTREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PTNE#WITH AREA CODE <br /> CAS <br /> ✓BOX CORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY` 0 ATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a public 2ency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION = 2 DISTRIBUTOR ✓IF INDIAN 1,1 OF TANKS AT SITE I E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR = 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 If WITH AREA CODE <br /> CJ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS \x ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNERCAREOF ADDRESS INFORMATION <br /> // a <br /> MAILING OR STREET ADDRESS ✓ box to indicate F-1 INDIVIDUAL LOCAL-AGENCY a STATE-AGENCY <br /> 5 14 )<CORPORATION [:] PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE IP CODE PHONE#WITH AREA CODE <br /> X ISO 1 61 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TIq HQ M44- - -7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) ,USED <br /> ✓box to indicate SELF-INSURED [-12 GUARANTEE Q 3 INSURANCE =4 SURETY BOND O 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> 0 8 STATE FUNDS CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&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.❑ 11.❑ 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) TANK OWNER'S TITLE DATTE� MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY Ali <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-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 6-95) <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI&TORAGE TANK REGULATIONS <br /> ( <br />