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ceo�n e <br />STATE OF CALIFORNIA hrP cO? <br />STATE WATER RESOURCES CONTROL BOARD 3 . <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />�� Ci C1lIfON H� <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ;!;L 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br />ONE ITEM a 2 INTERIM PERMIT F_� 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBAt FA LITY NAME <br />NAME OF OPERATOR <br />ADDRESS ] <br />NEAREST CROSS STREET <br />PARCEL#(OPTIONAL) <br />CITYNAME_� r �� <br />STATE <br />ZIP ODf <br />S1��0 E#WITHAREACODE <br />vc �r <br />� <br />C "- 1 <br />T DIC <br />NTECORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL -AGENCY Q COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINES 1 GAS STATION 0 2 DISTRIBUTOR <br />✓ IF INDIAN <br />OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />RESERVATION <br />Is <br />3 FARM O 4 PROCESSOR 0 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />r <br />It. PROPERTY OWNER INFORMATION - (MUST RE COMPLFTFD) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />0 ff <br />MAILING OR STREET ADDRESS <br />✓ box b ndicate INDIVIDUAL LOCAL -AGENCY (] STATE -AGENCY <br />CITY NAME <br />CORPORATION PARTNERSHIP COUNTY -AGENCY (] FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE It 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 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) HQ4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box Bo indicate 1 SELF-INSURED 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br />D 5 LETTEROFCREDIT 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. D II. 0 III. El <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 />COUNTY # <br />JURISDICTION # FACILITY # <br />LOCATION CODE - OPTIONAL CENSUS <br />SUPVISOR <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 />FORM A (5-91) FOR 5 <br />