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ebouR e <br />STATE OF CALIFORNIA APP • °o A <br />STATE WATER RESOURCES CONTROL BOARD 3. , <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Q� <br />• C��IFOR N.r <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY F__]1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE ITEM F—] 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE /,--/--7 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />/141-6 561vt <br />PHONE a WITH AREA rmiz <br />ADDRESS <br />� <br />NEARESTC�STR�� <br />PARCEL#(OPTIONAL) <br />� <br />(] COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />CITY NAME <br />STATE ZIP CODE <br />SLTE PHO E # WITH AREA CODE <br />STATE <br />-- <br />HOON9E #WITH AREA ��� <br />I PHONE # WITH AREA CODE <br />84,5 <br />✓ BOX <br />TO INDICATE CORPO ATION INDIVIDUAL PARTNERSHIP 0 LOCAL -AGENCY Q COUNTY -AGENCY 0 STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR <br />0 <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />R SEIF <br />RVATDION <br />3 FARM 4 PROCESSOR 0 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREACODE <br />DAYS: NAME (LAST, FIRST) <br />/141-6 561vt <br />PHONE a WITH AREA rmiz <br />NIGHTS: NAME (LAST, RST) PHONE # WITH AREA COD <br />NIGHTS: NAME (LAST, FIRST) <br />�i pc1) —9 7 —6 z_ <br />PHONE # WITH AREA CODE <br />If. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME 4W <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRE S <br />p/ � <br />✓ box to Indicate INDIVIDUAL <br />Q LOCAL -AGENCY 0 STATE -AGENCY <br />/� 7 <br />0 CORPORATION PARTNERSHIP <br />(] COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />SEA <br />= COUNTY -AGENCY = FEDERAL -AGENCY <br />ZIP CODE <br />STATE <br />-- <br />HOON9E #WITH AREA ��� <br />I PHONE # WITH AREA CODE <br />84,5 <br />� v <br />op-%) 56=� - / <br />111. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWN R <br />CARE OF ADDRESS INFORMATION <br />MAILING R STREET ADDRESS / <br />✓ box ID indicate = INDIVIDUAL <br />0 LOCAL -AGENCY 0 STATE -AGENCY <br />7 /V. <br />CORPORATION = PARTNERSHIP <br />= COUNTY -AGENCY = FEDERAL -AGENCY <br />CIN NAME <br />STATE <br />-- <br />ZIP CODE <br />I PHONE # WITH AREA CODE <br />84,5 <br />� v <br />op-%) 56=� - / <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 O 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br />O 5 LETTEROFCREDIT 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 checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. = It. F7 III. a <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYIYEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />134 LL I r I C,/ I vi <br />LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL U p.1TR7 ' OPTIONAL / <br />THIS FORM MUST BE ACCOMPANIED BY.AT LEAST (1) OR MORE PERMIT APPLIC RM B. UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORM A(5-91) 1113A•5 <br />