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e6ouR e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 5 , a oo <br /> o <br /> •rpt iFOR N�� <br /> � 11 MPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 5 CHANGE OF INFORMATION F_� 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM 2 INTERIM PERMIT _ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> > <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O CILITY N E NAME OF ATOR <br /> _ -#-gzq -2063 �� -/ <br /> ADDR S NJEAREST CROSSA <br /> EET PARCEL#(OPTIONAL) <br /> CITY N E STATE ZIP C E SITE PHONE#WITH AREA CODE <br /> CA 20 <br /> ✓ Box <br /> TO INDICATE COR RATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS EV t GAS STATION 2 DISTRIBUTOR / IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 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 /> PHONE*WITH AREA GODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS v ✓ box ID indicate D INDIVIDUAL <br /> 0 LOCAL-AGENCY 0STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE 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 ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP 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 j4I4L-[010 1 tj 9 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate __ <br /> ELF-INSURED [7j 2 GUARANTEE El 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT L___1 6 EXEMPTION Ll 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.E�l II.=1 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> OUNTY# JURISDICTION# At <br /> 39 1 I <br /> LOCATION OR¢Q E -OPTIONAL CENSUS TRACj#�OPPQN L SUPVISOR-DISTRICT CO OPTIO AL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNI/ SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 e1) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FOR0033A-R6 <br /> cic 0 <br /> �, <br />