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eyouR es <br /> STATE OF CALIFORNIA AP a cO <br /> STATE WATER RESOURCES CONTROL BOARD 3 9° <br /> UNDERGROUNDSTORAGE TANK PERMIT ALIC TI - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY � 1 PERMIT � 3 RENEWAL PERMIT CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPL TED) <br /> DBA OR FACT TY NAME to ME OF OPERATOR ®, <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME t STATE ZIP O / SITE PHONE#WITH AREA CODE <br /> (� CA <br /> ✓ BOX <br /> TOINDICATE IQ CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCYCOUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS IX I <br /> TYPE OF BUSINESS Q 1 GAS STATION 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR W 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA OD E DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) If 1PHONE#WITH AREA CODE NIGHTS: NAM (LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSp ✓box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 4!5 <br /> MAILING OR STREET ADDRESS !^/ ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 1 rZ 2,Z CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME S ATE ZIP CODE PHONE#WITH AREA COQE <br /> G 17 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE&COUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ R]4]-I I I I = /& /I/U 071 6" /V 06e1Vk_f <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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.F_� II.a 111. <br /> THIS FORM HAS BEEN COMPLETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> IV Z4 [711, 37 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOyR-DISTRICT CODE -OPTIONAL <br /> L.+ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FOKM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />