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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W der a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSE <br /> ONE ITEM E] 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE /JI <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) b� <br /> DBA OR FACILITY N E NAME OF OPERMAR r / <br />' ADDRESS � � �Q NEACROS�ET PARCEL#(OPTIONAL) <br /> C� <br /> CITY NAME STATE 7CODE SITE PHONE It WITH AREA CODE <br /> CA <br /> ✓BOX CORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 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 0 2 DISTRIBUTOR v'IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> � RESERVATION <br /> 0 3 FARM 0 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 It WITH AREA CODE <br /> ©// <br /> NIGHTS: NAME(LA9T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -- <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMA ION / <br /> MAILING ORSTREET ADDRESS ✓ box to indicate INDIVIDUAL E:]LOCAL-AGENCY STATE-AGENCY <br /> Ty �^ [_—]CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM / � �i• ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxio indicate INDIVIDUAL LOCAL-AGENCY a STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP D COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> O 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 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.D _j <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 MONTHiDAYNEAR <br /> I'Ce <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <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) OWNER MUST FILE THIS FORQH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRCTORAGE TANK REGULATIONS <br />