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SoURC, <br />e <br />STATE OF CALIFORNIA .P P CO <br />STATE WATER RESOURCES CONTROL BOARD 3 v`�., o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A awn <br />�7.,. o <br />�l IfORN <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT K5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 0 2 INTERIM PERMIT F__j 4 AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACI TY NAME <br />P. <br />DAYS: NAME (LAST, FIRST) <br />U 1510) —16 7 (f <br />NAME OF OPERATOR <br />NIGHTS: NAME(LAST FIRST) PH NE # WITH AREA CODE <br />IIC,(4A-R-) <br />ADD SS] <br />&S oto 46z-167 k/ <br />_y <br />/vYSTATE <br />NEAREST CROSS STREET <br />® <br />PARCEL # (OPTIONAL) <br />CITY AM <br />CITY NAME <br />c <br />STATE w __[ZIP <br />ZIP CODE <br />PHONE #WITH AREA CODE <br />SITE PHONE # WITH AREA CODE <br />✓ BOX <br />TO INDICATECORPORATION (] INDIVIDUAL PARTNERSHIP 0 LOCAL -AGENCY COUNTY -AGENCY <br />STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS�X1 GAS STATION <br />2 DISTRIBUTOR/ <br />IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />RESERVATION <br />O 3 FARM <br />4 PROCESSOR <br />= 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />DAYS: NAME (LAST, F ST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />U 1510) —16 7 (f <br />PHONE # WITH AREA rnnF: <br />NIGHTS: NAME(LAST FIRST) PH NE # WITH AREA CODE <br />IIC,(4A-R-) <br />NIGHTS: NAME (LAST, FIRST) <br />&S oto 46z-167 k/ <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME o <br />r / <br />CARE OF ADDRES INFORMATION <br />✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />0 CORPORATION Q PARTNERSHIP (] COUNTY -AGENCY (] FEDERAL -AGENCY <br />MA ING RST <br />S <br />✓ box to indicat E::] INDIVIDUAL <br />0 LOCAL -AGENCY STATE -AGENCY <br />® <br />CORPORATION PARTNERSHIP <br />0 COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />c <br />STATE w __[ZIP <br />C DE <br />PHONE #WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />0 CORPORATION Q 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 F41 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br />D 5 LETTER OF CREDIT 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. F__� II. 0 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 & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br />LOCAL AGENCY USE ONLY <br />ICOUNTY # JURISDICTION # FACILITY # <br />LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTION SUPVISOR - DISTRICT CODE - OPTIONAL <br />0/ a2 - <br />THIS FORM MUST BE ACCOMPANIED BY.AT LEAST (1) OR MORE PERMIT APPLICATION. FORM T, -UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORM A (5-91) 41 FOROq 33A•5 <br />