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E6o°" es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a �e <br /> CID PKETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED ITEE� <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAQ�FACILITY NAME ` x/ NAME OF O ERATgR <br /> AD���_E_ NEAREST O SS$'TREET PARCELN(OPfIONAL) <br /> CITYN /(/ (JO STATE (ZIP CSITE PHONE A WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TOINDICATE 0 CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS F__] 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN OF TA K AT!7. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 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 /> PNONF a WITH-------- <br /> NIGHTS: <br /> - ACONIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA Conp <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NArJ.c— USA <br /> CARE OF ADDRESS INFORMATION <br /> xnn P_b�&x" <br /> M OO SDRESS ll/1 q? <br /> ✓ yoxbirbicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ED CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> ColyA E ST&W ZIP CODE PHQNE#WITH AFIFA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4 LI-C Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate [j 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE RETY BOND <br /> C_J 5 LETTER OF CREDIT 6 EXEMPTION L] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unle4ANECT <br /> Led.CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: II. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRU <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 39: <br /> 2 EE <br /> LOCATIO TE OPTIONAL I CENSUS TRACT ISUPVI OR-D Op JTRICT CODE -OPTIONAL -- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1);OQ1 MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ,. <br /> FORM A(12-9,) FILE THIS FORM WITH THE LOC;4L'1(GENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • C/�.e ' �� ,,.7 � /S /� FOR0033A-R6 <br />