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1.01 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ° <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT [__] 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> Ali <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O(q��"/,pCILITY <br /> ADDRE NAME NAME OF OPERATOR <br /> /�� NEAREST CROSS STREET PAfICELN(OPTgNAL) <br /> CITU AME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> BOXTO INDICATE (]CORPORATION E__1 INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY I�COUNTYAGENCY (] STATE AGENCY FEDERALAGENCV <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR (] RESERVATION/ IF INDIAN #OF TANKS A ITE I E.P.A. I.D.#(WknWj <br /> Q 3 FARM O 4 PROCESSOR O 5 OTHEROR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO ACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHnNE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bexblMb = INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-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 ✓6°a blMb� OINDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> I�CORPORATION PARTNERSMP 0 COUNTY-AGENCY Q FEDEPALAGENCY <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) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED <br /> ✓C biMicale I= I SELF INSURED UARAWEE 0 3 INSURANCE (]4 SURETY BOND <br /> I=5 LETTEROFCREDIT 10 EXEMPTION [D 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 II.0 III.0 <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 MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# /.67M.p-1#- JURISDICTION# FACILITY <br /> LOCATION CQOE -OPTIONAL CENSUS TRMT# OPTIOOPONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 1 37-1 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LLLEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A 55 \\` <br /> `0 <br />