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jSTATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />k—� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED <br />0 <br />ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE D 5 <br />I FArll ITVISITF INFORMATION R ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME/) <br />CARE OF ADDRESS INFORMATION <br />4t-e�-s <br />NAME OF OPERATOR <br />STATE <br />MAIL) STR ET ADDRESS <br />PHONE # WITH AREA CODE <br />✓ box to indicate INDIVIDUAL LOCAL -AGENCY 0STATE-AGENCY <br />.rR <br />`(f40 # <br />ADDRESS <br />(� CORPORATION = PARTNERSHIP = COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME% <br />NEAREST CROSS STREET <br />STATE <br />PARCEL # (OPTIONAL) <br />PHONE # WITH AREA CODE <br />7 - <br />CITY NAME <br />ST <br />ZIP CODE � <br />� <br />SITE PHONEj# WITHEA CODE <br />CEA <br />1 <br />✓ BOX <br />TO INDICATE CORPORATION <br />(] INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY 0 COUNTY -AGENCY <br />0 STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />1 GAS STATION 0 2 DISTRIBUTOR✓ <br />IF <br />IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />O <br />3 FARM <br />4 PROCESSOR = 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />u DDnDGRTV 0M/NPR INFnRMATIOM . IMI IST RF CnMPI FTFDI <br />NAME (Zr <br />r 6 <br />CARE OF ADDRESS INFORMATION <br />4t-e�-s <br />CARE OF DDRESS INFORMATION <br />STATE <br />MAIL) STR ET ADDRESS <br />PHONE # WITH AREA CODE <br />✓ box to indicate INDIVIDUAL LOCAL -AGENCY 0STATE-AGENCY <br />.rR <br />`(f40 # <br />/ / <br />(� CORPORATION = PARTNERSHIP = COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME% <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />7 - <br />III_ TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />MAILING OR STREET ADDRESS <br />CARE OF ADDRESS INFORMATION <br />✓ box to indicate INDIVIDUAL] LOCAL -AGENCY 0 STATE -AGENCY <br />= CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />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 4 4 - I C510 O 614] <br />V. PETROLEUM UST FINANCIAL,,FiESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate J ' SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND I <br />0 5 LETTEROFCREDIT O 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 checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II III. 0 <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 MONTWDAYIYEAR <br />LOCAL AGENCY USE ONLY 1tKCVZ> <br />COUNTY # JURISDICTION # FACII/LITY # <br />a �!� <br />LOCATION CODE - OPTIONAL I CENSUS TRACT # - OPTIONAL I SUPVISOR - DISTRICT CODE - OPTIONAL <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 />FUHM A(5-91) 4 ��� rvrsuwsn <br />4 <br />