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^�60U. <br />STATE OF CALIFORNIA a °Os, <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� "� <br />L�O`l inOn Yin <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ] PERMANENTLY CLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE 53 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPI FTFDT <br />DBA R FACILITY NAME _hb"� ^�� ,n <br />IVT/T� •J( <br />NAME OF ERATOR <br />ADDR SS <br />W` 5 <br />NEAREST ROSSS EET <br />PMCEL#IOPrK1NAy <br />CITYSTATE <br />ZIP CODE <br />ZIP C7, <br />517E PHONE #WITH AREA CODE <br />CA <br />✓ BOX <br />TO INDICATE 0 CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL -AGENCY [__1 COUNTY.AGENCY D STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORO <br />✓ IF INDIAN <br />4 OF TANKS qT SITE <br />E. P. A. I. D. # (aplipralJ <br />0 3 FARM Q 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />/ <br />EMERGENCY CONTACT PERSON (PRIMARY) FMFRGFNCY CONTACT RFRSnNI IRFrnbnA0V1-..,.1.....1 <br />DAYS: NAME (LAST, FIRST) <br />PHONE A WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE A WITH AREA r�E <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE A WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />11. PROPERTY OWNER INFORMATION - (MUST BE COMPI FTFD1 <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ boxbllbba4 = INDIVIDUAL O LOCAL -AGENCY 0 STATE -AGENCY <br />O CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY D FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE A WITH AREA CODE <br />III. TANK OWNER INFORMATION. !MI IRT RF PnMPl FTFn) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ boxbintlicam I= INDIVIDUAL O LOCAL -AGENCY 0 STATE -AGENCY <br />CORPORATION = PARTNERSHIP = COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE N WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4 0 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMP ED) — IDENTIFY THE METHOD(S) USED <br />✓ box bilbbale t] 1 SELF-INSURED 0 2 ARANTEE L-1 3 INSURANCE 0 4 SURETY BONG <br />= 5 LETTER OFCREDR LDf EXEMPTION 0 %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: L [::] II. 0 III. D <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />LU(;AL AGENCY USE ONLY <br />COUNTY# oa%4 #- JURISDICTION# FACILITY# <br />LOCATION CODr fflI7NAL CENSUSTRAQ V DP11ONAL SUPVISO -DISTRICT CODE -OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY.AATT LEEASGT (l)/NOIR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />/ L FOR ]AS <br />