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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e- -- <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE 'Ig <br /> MARK ONLY LJ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY LOSE <br /> ONE ITEM U 2 INTERIM PERMIT F__1, A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR fAGI ITY NAME � ( NAM OPERATOR <br /> A RESS NEARESTCROSS STREET PAIICEL/(OPTIONAq <br /> CITY NA� STA ZIP Ep- §WE PHONE s WITH AREA CODE� <br /> TOI/ BOX <br /> INDICATE Q CORPORATIONNDIVIDUAL Q PARTNERSHIP Q p TGENCY IQ COUNTYJ#GENCY Q STATE-AGENCY Q FEDEPALAGENCY <br /> ISTRIC <br /> TYPE OF BUSINESS I GAS STATION IQ 2 DISTRIBUTOR 0 RE/ IF INDIAN <br /> s OF TANKS AT SITE E.P.A. 1.D.a(optional) <br /> 3 FARM O ATION <br /> 4 PROCESSOR Q 5 OTHER pp TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYSCODE DAYS: NAME(UST,FIRST) <br /> .FRI <br /> F I7o00npA ming <br /> TSNAME(LASTFlr E NIGHTS: NAME(LAST,FIRS <br /> T)NIG WH AR <br /> t �/ <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED) 1I LW eo C, <br /> NAM CARE OF ADDRESS INFORMATION <br /> MAIL.WG OR STREET ADDRESS ✓ box 0Wic u CRITiNorviDuAL Q IOCALAGBICY Q STATE-AGENCY <br /> AJANCORPORATION Q PARTNERSHIP Q COUNTYlAGENCY FEDERA <br /> L-AGENYjj � ZIP CODE PJAONE 0 WITH AREA CODE <br /> CIY SN/ 1 2-1 <br /> 111. TANK INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWN Uv CARE OF ADDRESS INFORMATION <br /> 4 <br /> MAILING OR STREET ADDRESS ✓ bmga xM m Q INDIVIDUAL Q LOCAL-AGENCY STATE-AW4CY <br /> Q CORPORATION Q PARTNERSHIP Q COUIM-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x 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 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ r— <br /> Ooz biMkala , 1 SELF INSURED Q 2 GUARANTEE Q 3 INSURANCE Q a SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 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. 11.= 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 B SIGNATURE) PPLICANYS TITLE DATE MONTWDAYNEAR <br /> /yi1U,/, A7Aiy/l��iD BlliNc,� // <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION N FACILITY» <br /> Tl_ 10 �4 0 5 <br /> - - TRACT- OPTHJ- - - - - <br /> LOCATONCOOE CP IIONAL CENSUS TRACTS � NAL SUPVISO�ISTRICT CODE OP ZONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLE THIS IS A C NGEOF SITE INFORMATION NLY. <br /> IORNI A,12 9.". FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETw REGULATIONS �� �� <br />