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0 0sou e <br /> t <br /> STATE OF CALIFORNIA APS ' cO <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A Q�� ,fin <br /> :77 o�[Ifoft N/'• <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 I NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSEp 8{! <br /> ONE ITEM 2 INTERIM PERMIT F__j 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA QJWACILITY NAME dY NAME OF OPERATOR <br /> AD S a v NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE TZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TO INDICATE (]CORPORATION [] INDIVIDUAL = PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY [] STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION 0 2 DISTRIBUTORR SE F INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O 3 FARM 0 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) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to Indicate INDIVIDUAL LOCAL-AGENCY <br /> Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Indicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION Q 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) HOFF_4 - p 0 3 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate I SELF-INSURED 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= 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 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 6 JURISDICTION# FACILITY# 4`' <br /> c ) 3D a� <br /> LOCATION CODE -OPTIONAL �CENSUSTRACTg -0 PTI¢/6 SUPVISOR-DISTRICT C0,11E -OPTIONAL <br /> 22 Fy <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CH� E SITE INFORMATION ONLY. <br /> FORM A(5-91) � � FORO�A _7 <br /> - <br /> 0 <br /> S�b�(r�,2� 6'� <br />