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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD =� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH F CILRY/SRE <br /> MARKONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [—] 7 PERMANENT <br /> ONE REM ❑ 2 INTERIM PERMIT D SITE <br /> ❑ 4 AMENDED PERMIT ❑ g TEMPORARY SITE CLOSURE <br /> 3 <br /> I. FACILRYlSITE INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> DBA OR FACILITY NAME r � NAME OF OPERATOR <br /> ADDRESS /.- <br /> 3. p- NEAREST CROSS ST/REST PARCEL#(OPrIDNAU <br /> CITY NAME <br /> // STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA9-5- 2-05— <br /> ✓ Box <br /> TO INDICATE p CORPORATION p INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY p COUNTYAGENCV <br /> DISTRICTS pSTATE-AGENCY p FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.R A _1D #Iwk# ) <br /> Q 3 FARM O 4 PROCESSOR 5 OTHER I❑ RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 2 pLF3-?o <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME S / CARE OF ADDRESS INFORMATION <br /> u �-..e a,o 4 h u'we— <br /> MAILINGORSTREETADDRESS On bbdoY p INDIVIDUAL 0 LOCALAGENCY 0 STATE-AGENCY <br /> p CORPORATION p PARTNERSHIP p coUNTY#GENCY p FEOERALAGENCY <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 bNomwimM Q INDIVIDUAL p LOCAL AGENCY p StATEAGFNCY <br /> Q CORPORATION = PARTNERSHIP p COU INAGENCY E::] FEDERWIGENCY <br /> CITY NAME STATE 1 ZIP CODE PHONE S 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 - 3 a 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ box b alka O 1 SELF-INSURED 0 2 GUARANTEE p 3 INSURANCE Q 4 SURETY BOND <br /> D 5 LETTEROFCREOT 9 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 AI's checked. <br /> CHECK ONE BOX INDICATING M41CH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.❑ 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(PRINTED b SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 57-y11A.)1 sf <br /> It/1 -37 y <br /> LOCATION CODE -(W770ANL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> zs v 2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY/ <br /> FORM A(5.91) DR,0gE3 <br /> /� F AS <br />