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f" <br /> � . • Svyp�e5 <br /> STATE OF CALIFORNIA �� ? <br /> STATE WATER RESOURCES CONTROL BOARD ;��,�, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m, <br /> COVfLETETHIS FORM FOR EAC ILITYISITE <br /> MARK ONLY 1 NEW PERMIT RENEWAL PERMIT Ftr5 CHANGE OF INFORMATION r 7 PER ENTLY SED SITE <br /> ONE ITEM U 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE qq <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) �� <br /> DBA . A ILITY NAME t( NA OF OPERATOR <br /> A RES i NEARE ROSS STP ET PARCEL#(OPTIONAL) <br /> CITY NAME - STACE4 i ZICqODE SITE PHCLNE aTH AREA CODE <br /> IR <br /> TO INDICATE COR RATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY (7Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR RESEF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM a 4 PROCESSOR 0 5 OTHER OR TRUST LANDS C) <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 A WITH AREA MIDE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE s WITH <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILI R STREET AD ESS /O �'j ✓ box io indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP 1 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ME ST CODE HONE#WITH AREA ODE <br /> 4�51 - 0 <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME W RCARE OF ADDRESS INFORMATION <br /> MAILlN uR S EET SS• /' ✓ box bind�ca[e INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> /{�i/J =CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM STr ZIPVDE � � H E#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)(3223-9555 if questions arise. <br /> TY(TK) HQ 7L <br /> I- � <br /> V. PETROLEUM UST FINANCI PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 9 INSURANCE 4 SURETY BOND <br /> C 5 LETTEROFCREDIT 6 EXEMPTION 99 OTHER Of <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II i ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. 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 /> COUNTY# / JURISDICTION N FACILITY# <br /> '_OCATiON E OPTIONAL CENSUS TRACT OPT SUPVISOR-DI TRIC 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 /> CORM A(12 9n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> R0033A-R6 <br />