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• • �50URCES <br />STATE OF CALIFORNIA Ag P cO <br />STATE WATER RESOURCES CONTROL BOARD 3 <br />UNDERGROUND ST GE TANK PERMIT APPLICATION - FORM A < o <br />C��IFOP N,� <br />C � -;1ETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑1 NEW PERMIT ENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOS <br />ONE ITEM❑ 2 INTERIM PERMIT Y4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADD R SS - (MUST BE COMPLETED) <br />DBA 0 A LITY NAME <br />/ <br />/� <br />NA / OF OP RATOR (� <br />A R S <br />% <br />FARE ROSS STRrEET I <br />PARCEL # (OPTIONAL) <br />- <br />!/� <br />D(! <br />CITY NAME <br />STATE ZI�ODE <br />SITE PH E # WITH AREA CODE <br />cA <br />-- ✓ BOX <br />TO INDICATE COR RATION <br />0 INDIVIDUAL PARTNERSHIP 0 LOCAL -AGENCY COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />[7E:OF BUSINESS 1 GAS STATION 2 DISTRIBUTORR <br />IF INDIAN <br /># OF TANKAT SITE <br />E. P. A. I. D. # (optional) <br />SER AT <br />0 3 FARM <br />4 PROCESSOR = 5 OTHER <br />OR TRUST LANDS <br />VC) <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHQNF 9 WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />If. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME _ / / / _ _ CARE OF ADDRESS INFORMATION 1 <br />MAILI R TREET AD ESS / ✓ box toindicate 0 INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY <br />CORPORATION 0 PARTNERSHIP COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY S JEA 7�0� 1'�,? HONE WITH ARELAE C�n7 _11„A <br />111. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME W R <br />r <br />CARE OF ADDRESS INFORMATION <br />MAILIN R STREET ADgRESx <br />RE <br />O L D� <br />box 6o indicate INDIVIDUAL (� LOCAL -AGENCY (� STATE -AGENCY <br />CORPORATION <br />� CORPORATION PARTNERSHIP Q COUNTY -AGENCY 0 FEDERAL -AGENCY <br />✓�c( <br />CITY NAM <br />ST)JA <br />ZIP DE S H # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ Q <br />V. PETROLEUM UST FINANC1! �PONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE <br />L� 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 c <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ I- <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AN <br />I. ❑ <br />APPLICANT'S NAME (PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />BOND <br />COUNTY #JURISDICTION <br /># <br />FACILITY # <br />LOCATION fE OPTIONAL <br />ICE SUS TRACT # - OPT �O <br />s <br />SUPVISOR - D STRIC 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 />FORM A (12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />• • fR(033A-R6 <br />