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LbV�wCC9 <br /> STATE OF CALIFORNIA 'S ` <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FORE ACILITYISITE YYYIII ' <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 TLX CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET / PARCEL$(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Box <br /> ca 9 s 37 � <br /> TOINDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTYaGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 t GAS STATION Q 2 DISTRIBUTOR RESERVATION ,,Or TANK T SITE E.P.A. I.D.x(optional) <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT P ON (SECONDARY)•optional <br /> DAYS: M� FIRST) PHONE a WITH AREAf,O E � A :NAME(LAST,FIRST) <br /> l <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NI TS: NAME(LAST IRST) �w <br /> M COMPLETED) <br /> II. PROPERTY OWNER INFORMATION• MUST BE CO D E <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSKue Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ✓ <br /> a 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEOERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE t WITH AREA C,QOE . <br /> /5" 0, <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER 51+-Me A­ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS e ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE ( PHONE x WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(910)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - D 10 161d <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate Q I SELF-INSURED Q 2 GUARANTEE Q 3 1 FIANCE Q 4 SURETY cONO <br /> Q S LETTEROFCREDIT Q 6 EXEMPTION 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 c ked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL 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 MONTWOAYNFAR <br /> Vv <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION it FACILITY x <br /> C S �� 10101 <br /> LOCATION CO -OPTIONAL (CENSUS TRACT a -OPTIONAL (SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UN ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> A(5.91) FCR0033A•5 � <br /> w <br />