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•'e6a�A <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A : a <br />0 <br />• C�(IPON N.� <br />COMPLETE THIS FORM FOR EA FACILITYISITE <br />MARK ONLY F—] 1 NEW PERMIT F__] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEDSITE <br />ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 7 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME � n <br />PHONE # WITH AREA CODE <br />NAME OF OPERATOR <br />AR 41111 O <br />v <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />ZIP CODE :7[PHONE <br />AD RISS � <br />(j// <br />NEARE TCROSSSTREET / <br />I <br />PARCEL#(OPTIONAL) <br />CITY NAME <br />STATEZIP <br />C E <br />SITE PHONE # WITH AREA CODE <br />CA <br />�5Z0 <br />✓ BOX <br />TO INDICATE <br />O CORPORATION INDIVIDUAL = PARTNERSHIP <br />LOCAL -AGENCY 0 COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />= 1 GAS STATION 2 DISTRIBUTOR0 <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />R SERVNDIAN ATION <br />0 3 FARM 0 4 PROCESSOR = <br />5 OTHER <br />OR TRUST LANDS <br />..rJr7 <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 />PHONE 4 WITH AREA GnDF <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />1. PROPERTY <br />%OWNER INFORMATION - MUST BE COMPPL <br />rA <br />ME 0lLlrR0REETAD 0 <br />CITY NAVE tt �f�J. X <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />CARE OF ADDRESS INFORMATION <br />✓ box to indicate INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY <br />CORPORATION PARTNERSHIP ! 6/ COUNTY -AGENCY FEDERAL -AGENCY <br />STFZ <br />� 7_to(D WITHA <br />�' -A(�D(�D .5J/ <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 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE :7[PHONE <br />#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 - d <br />V. PETROLEUM UST FINANCI RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box bindicate FV 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE E::] 4 SURETY BOND <br />D 5 LETTER OF CREDIT Q 6 EXEMPTION 0 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 ecked. <br />FCK 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 MONTHIDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # qlq -7, <br />Pj,_ <br />LOCATION CO�'OPTIONAL CENSUS TRACT #-QPT,tpNAL SUPVISO -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 />FORM A (5-91) FOR0033A-5 <br />