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60JM t <br /> STATE OF CALIFORNIA .J c' <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W m� "' <br /> COMPLETE THIS FORM FOR EACH 5CILITYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLLCLqqWa.4E <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA TJO OR FACILITY STAT <br /> NA NAME OF OPERATOR <br /> C ' c, C 6 <br /> ADDRESS/� NEAREST CROSS STREET PARCELO(OPrIONAL) <br /> d 0 0 r <br /> CITY NAME E CODE SITE PHONE#WITH AREA CODE <br /> cA `f D <br /> ✓ WXCORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY Q FEDEML-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS O , (IAS STATION 0 2 DISTRIBUTOR / = RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(OpfianaO <br /> 0 3 FARM 4 PROCESSOR ,L1`CLJ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) )•optional <br /> rP: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LASTwCA"SEA DO <br /> HTS: NAME(LAST.FIRST) PHONE#WITH AREA CODETS: NA E(LAST,FIRST7 PHONE' WITH AREA CODE) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ wxbindlrab INDIVIDUAL (] LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> II FTROF OW NECARE OF A IJDDREPSINFC.RMATIT�, <br /> 1 <br /> M ILING OR STREET ADDRESS ✓ box b Ind ate INDIVIDUAL O LOCAL-AGENCY 0 STATE- <br /> AGENCY <br /> a Q CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CI M STATE_ ZIP CODE 2 PHONE#WITH AREA CODE <br /> ACCOUNTFEE NUMBER'--Call <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Dox blMicale I SELF-INSURED E�71 2 GUARANTEE (] 3 INSURANCE E-1 A SURETY BOND <br /> D 5 LETTEROFCREDR L-15 EXEMPTION 0 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.O 11.[7] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR INTED S S IGNATURE) APPLICANTS TITLE DATE MONTWDAYYEAR <br /> LOCAL AGENCY USE ONLY 4c, 'Crneo x�� <br /> COUNTY# JURISDICTION# FACILr�TY#(�dF/'S7) <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3. <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(S91) FOR0033A 5 <br />