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�\ t40 up N <br /> STATE OF CALIFORNIA g ' <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> L' COMPLETE THIS FORM FOR EA H FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY ME Dir�,f NAME OF OPEyAsTOR <br /> N OL <br /> ADDRESS Lf NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> 3 F• <br /> CITYNAME - STATEZIP CODE SITEPHO% WITNAREA CODE <br /> CA S - b <br /> ✓ BOXTOINgCATE In CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 3 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D.#(aplimal) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) WITH AREA COOP <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> 2 - - CARE OF ADDRESS INFORMATION <br /> AILING TR TADDRESS 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAM .1 STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> 41 12 <br /> III. TANK OWN R INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bDx binftaU 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O 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 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindkm O 1 SELF-INSURED 0 2 OUMAMEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTEROFCREDR 8 E%EMPT ON 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 c ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.v III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST DF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1 f9xn+r z <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> -23. 90 37-1s:— <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( -91) FOIR093333JA-5 <br /> 13 G CA <br />