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+ 1 S vR.• <br /> Z <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> !--�� COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> CNE ITEM r, 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> CBA OR FACILITY NAME e /'�i (Ing— S NAME OF OPERATOR <br /> ACDRESS I_ NEAREST CR SST5K /� PARCEL#(OPTIONAL) <br /> CC��rskf.,� <br /> CITY NAME STATE ZIP C <br /> 6 SITE PHONE#WITH AREA CODE <br /> CA <br /> TOINDIC TE Q CORPORATION Q INDIVIDUAL Q PARTNERS Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION (Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optionao <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA r()DF <br /> PHONE#WITH AREA COOP <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME L A-0 <br /> K/�- _ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORE S �i, ✓ box to indicate <br /> Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY <br /> (, Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CO 7 PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST 6E COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILSNG OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Ql PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 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 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate Q 1 SELF-INSURED (Q 2 GUARAN7cE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 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 ked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= 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 MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> CO # � �1 rJURISDICTION# FACILITY# <br /> 19T [aoul <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 /> FORMA(5-91) — �/�� FOR0033A-5 <br />