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fty Va f <br /> CO <br /> STATE OF CALIFORNIA <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD 3 ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o ter, <br /> C�L,iOf Y,f <br /> V COMPLETETHIS FORM FOR EACH FACILRYISRE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMAN TLY CL�� <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FFACILITY NAME NAME OF OPERATOR <br /> r Zt771" <br /> � <br /> ADDRESS NEAREST CROSS STREET PARCELS(OPTIONAL) <br /> 5 U ( <br /> CITY NAME STATE ZIP CO E li SITE PHONE#WITH AREA CODE <br /> CA J <br /> TOIN Box l�CORPORATION �IPARTNERSHIP DISTRICTS CAL-AGENCY D COUNTY-AGENCY f� STATE-AGENCY I� FEDERAL AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR gESE RVATDIOAN N #OF TANKSIAT SITE E.P.A. I.D.#(Opdi l) <br /> 0 3 FARM O 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) PHONE*WITH AREA rOD <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS `1 bOx b Nita L=l INDIVIDUAL O LOCAL AGENCY STATE-AGENCY <br /> =CORPORATION I= PARTNERSHIP 0 COUNTY-AGENCY Q FEDEML-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- ✓ Lox umdic" D INDIVIDUAL LOCAL-AGENCY O STATEAGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTYAGENCY 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 [4T4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bax miMmale O 1 SELF-INSURED 0 2 GUARANTEE [] 3 INSURANCE O 4 SURETY BONG <br /> 0 5 LETEROFCREDT I=6 EXEMPTION -]99 OTHER <br /> 71 <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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> -7-2 -� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# � JURISDICTION FACILITY# <br /> (�I 'L7:9 , ZLJ <br /> LOCATION POPE OPTIONAL ICENSUS TRACT# -OP7I0SUPVI�OR3TRICT CODE -OPTIONAL <br /> 22 / I/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORKA8060NLY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR09633AR6 <br />