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*%%' <br /> STATE OF CALIFORNIA °, <br /> STATE WATER RESOURCES CONTROL BOARD ;�¢. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� =e <br /> C MPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION F:] T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACIu NAM NAMEOFOPERATOR <br /> ADDRESS NEARESF CROSS STREET PAI(OPTIONAL) <br /> 44 7 4 49,Ml-/aId 9 <br /> CITY NAME_ It CA <br /> CA 21P SI SNE#JITHEA ARCODEBox <br /> /O <br /> TO INDICATEO CORPORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY GD/y COUNTY-AGENCYI� STATE-AGENCY 73OYFEDEM/LLAAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ T GAS STATION [:] 2 DISTRIBUTOR ❑ q SE IF RVADTION IS OF TANKS AT 917E E.P.A. I.D.#(apfianal) <br /> ❑ 3 FARM ❑ 4 PROCESSOR OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHON #WITH AREA CODE D D NAME(L(ST,FIRSn `2 —030z, <br /> NIH Ael (LST.FIRSn PHONE#3W13T�A=CODE NIGHTS:C=•`AME(LASIIT,FYYIIR9n <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAP �L w CARE OF ADDRESS INFORMATION <br /> MAIL OR STREET DRESS - ✓ bb l 0 INDIVIDUAL 0 LOCAL-AGENCY I�STATEAGFNCY <br /> , 0 • O CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATF_,a ZIP CODS. PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NASO OWNER ARE OF ADDRESS INFORMATION <br /> G <br /> MAIL( OR STREETS�DDRES ✓box OkWicak = INDIVIDUAL LOCAL-AGENCY =STATE-AGENCY <br /> IA�• D- /LJd zq 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME - STAT[ 21P LADE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBBEE�Rt-Call(916�j)323-95t5 if questions arise. <br /> TY(TK) HQ 4 4 -F <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ hox mirdkate = I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> 0 5 IETTEROFCREDIT E-j 6 EXEMPTION 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: 1.[:] II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND 60RRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It <br /> 311L-li 3 r � Z <br /> LOCATIONCODE OPTIONAL CENSUSTRA -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATINNNYY•- FORM <br /> ORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONJS /�i/ / <br /> v �/ FOR0033AR6 <br />