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r�2�tR tEs C <br /> STATE OF CALIFORNIA A °� <br /> STATE WATER RESOURCES CONTROL BOARD a` r o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> •�l rf OP N' <br /> COMPLETE THIS FORM FOR E4 FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F_� 7 PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R FACILITY NAME NA F OPERATOR <br /> Card lcr�c� ©`� e .�L <br /> AD ESS N A ST CROSS TREET +PARgh#(OPTIONAL) <br /> - mak& vCITY NAME STATE ZIP C E PHONE#WITH AREA CODE <br /> B CA <br /> ✓ Box — <br /> TO INDICATE IVCORPORATION L_:1 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY EIJ STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 02 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> hlyY�#S/�//N�E(�T,FI � /y� � PHONE#W,TH EA CODE DAYS: NAME(LAST,FIRST) <br /> /��- 2HONF X WITH AREA GOOF <br /> TS: NAME(LAST,FIRST)_? PHONE#VyjTH /DEQ i��) NIGHTS: NAME(LAST,FIRST) <br /> t C CpJ1C�/• / L// r/ <br /> z a&�� - PHONE#WITH AREA COOP <br /> II. PROPERTY <br /> �.-OWNER <br /> IINNFORM TION• MUST BE COMPLETED <br /> N / <br /> ran r l/�✓T her50/� CARE OF ADDRESS INFORMATION <br /> MAILIy TR ETES . // ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY (] STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITYN E ST � ZIP GQz6 PONE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• vv box to indicate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY 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 L4 4�-�D�2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM LETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED E:]AUARANTEE 3 INSURANCE [::J,,4 SURETY BOND <br /> C� 5 LETTER OF CREDIT EV6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[_�] 1111. <br /> THIS FORM,HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAPIRRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> G <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY# <br /> 1-__❑ <br /> LOCATION CODED QPTIONAL CENSUZ �/1�T CT -QPTIONAL !SUPVISOR-D STIR CT -OPTIONAL <br /> I <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 /> 0 0 FOR0033A-R6 <br />