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gOUA [ <br /> e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4 <br /> •Cit�fOR N•[. <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> LY � 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITY, <br /> NE ITEM E] 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R F ILI NA 4_ J �^ NAME OF P ATOP <br /> ADDR SyS / L//' NEAREST OSS`STREET PAR L#(OP TONAL) <br /> d v� <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 9 D <br /> ✓ BOX <br /> TO INDICATE ORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS = 1 GAS STATION O 2 DISTRIBUTOR / IF INDIAN #OF TANS T SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> a 3 FARM 0 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> #WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bIndicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> O R C E OF ADDRESS INFORMAT <br /> INDIVIDUAL (� LGE 0 STATE-AGENCY <br /> I INC,P06R6T AD ES ✓box b indicate <br /> 6U Q CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> OK�/ ST,AJE/4 ZIP CO E / n o� PHONE#WITH AREA CODE_ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER/-Call(916)323-9555 if Jquestions arise. <br /> (Jf/_ <br /> TY(TK) HQ 4 4 -1 01Z Iq j!j 15S <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b Indicate 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> =5 LETTEROFCREDIT 0 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 check <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORREC <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# _ JURISDICTION# FACILITY# <br /> ® Ho 'l� <br /> LOCATION CQ61E -OPTIONAL CENSUS TRA #_OPTIOfVAL, SUPVISOR-DISTRICT CODE -OPTIONALr <br /> %Vt J� O <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 /> FORM A(5-91) FORIWIA-5 <br />