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Ee°u"ces <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :��� &' <br /> COMPLETE THIS FORM FOR EAC ACILITY/S[TE <br /> MARK ONLY ❑ EW PERMIT F—] 3 RENEWAL PERMIT EPT"5 CHANGE OF INFORMATION 7 PERMANENT Y CLOSED <br /> ONE ITEM LJ 2 INTERIM PERMIT 4 AM 6 TEMPORARY SITE CLOSURE a <br /> I. FACILITY/SI INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> r <br /> I SIB ({ NEARESTC S S REET/ PARCELN(OPTIONAL)ME STATE ZIP COSITE PHONE#WITH A ACODE <br /> CAOZBOX IF <br /> INDIC TE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY (]COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR0 RESER INDDIAN #OF TAN S AT SITE I E.P.A. I.D.#(optional) <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH A EA COD DAY ( FIRST) <br /> - ? � <br /> NIGHTS: N (LAST,FIR PHONE#WITH AREA CO E NIGHTS: NAM LAST IRST) <br /> PHONE#VITH AREA <br /> P NER INFORMATION-(MUST,$E COMPLETED <br /> NAME �} RE OF ADDRESS INFORMATION <br /> V �� aS <br /> MAILING ORS REET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAMEJ STATE ZIP CODE PHONE N WITH AREA C DE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD SS• ✓ box b indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION [] PARTNERSHIP 0 COUNTY-AGENCY I] FEDERAL-AGENCY <br /> CITY NAME STATE 7 CODE PHONE#WITH AREA CODE <br /> c <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4Lj-� &'�f -F, <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—ID IFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED I]2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 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 o er unless bo I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.U III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDG&Ij TR AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY (� <br /> COUNTY# JURISDICTION# FACILITY# <br /> i lLl IT 0 <br /> 7::) <br /> - - - --- - - <br /> ///n 4 411 <br /> LOCATION CODE OPTI AL I CENSUS TRAQT# -OPTIONAL SUPVI R-DI <br /> 0K <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFO N ON Y. <br /> FORM A(12 91) FILE THIS FORM WITHTHE OCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br />