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.r l <br /> �souu e. <br /> STATE OF CALIFORNIA A� COtia <br /> STATE WATER RESOURCES CONTROL BOARD W <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A y; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT n 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACILITY NAM NAME OF OPERATOR <br /> �` <br /> ADDRES NEAREST CROSS STR ET PARCEL#(OPTIONAL) <br /> INAME e'�O STACE� ZIP C DE S TE PHOWE X WITH AREA CODE <br /> ✓ Box <br /> TO INDICATE CORPORATION F-1 INDIVIDUAL 0 PARTNERSHIP (-1 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAS , IRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE A CODE <br /> If. PROPERTY OWNR INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindicate 0 INDIVIDUAL LOCAL-AGENCY <br /> 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMA ION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate 0 INDIVIDUAL LOCAL-AGENCY <br /> (] STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UARESPONSIBI <br /> E ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4 444�- <br /> V. PETROLEUM UST FINANCIAL Y-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate = 1 SELF-INSURED =2 GUARANTEE = 3 INSURANCE 4 SURETY 90ND <br /> L=1 5 LETTER OF CREDIT 6 EXEMPTION A 999 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.El II.El 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# JURISDICTION#-"til- FACILITY# <br /> I- _I � 4 a 3 <br /> -- - - - - <br /> LOCATION CO E 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 /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK R&3- ?31:4_ <br /> TION� <br /> 0 FOR003 - <br /> V\ <br />