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d � t <br /> STATE OF CALIFORNIA ° ' �5 <br /> STATE WATER RESOURCES CONTROL BOARD W�+g' n o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE "'O""�- <br /> MARK ONLY p 1 NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION [Ij 7 PERMANE LY CLOSED S <br /> ONE REM Q 2 INTERIM PERMIT Q 6 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAMENAMEOFOPERAT R <br /> ADDRESS NEAREST CROSS STREET P CELi(ORDNAU <br /> CITY NAME ® + STATE ZIP COj�C, SYTE RHONE i WRH AREA <br /> ll/ CA 7 <br /> BOX INDIVIDUAL PARNERSHIP AGENCV Q COUNTYAGENCY' STATE-AGENCY• FEDERALAGENCY' <br /> TOIN DBT <br /> 'Xow,wolU saPcnzcRAphe <br /> lolowing:name of SupmIsor of division.section,or oNics which opwatn the UST <br /> TYPE OF BUSINES t GAS STATK)N Q 2 DISTRIBUTOR Q ✓ IF INDIAN i OF TANKS AT SITE .A I.D.a(aP1iwIJ <br /> RESERVATION <br /> Q 3 F PROCESSOR EX 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: A PIRST <br /> HONE i W REA DE DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> / GY' <br /> NIGHTS: NAME PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE i WITH AREA CODE <br /> n. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMES L L CARE OF ADDED INF TpN �, <br /> NIAILINGITr T ESS / , ✓�b INDIIVVIIDUAL LOCAL AGENCY [DSTATE-AGENCY <br /> 6 .Q CORPORATION C3 PARTNERSHIP COUNTYAGENOY =FEOERALAGENCY <br /> CITY-NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> �� 14 06 0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER SJ� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET b9Xbiotlb#e 0 INDIVIDUAL LOCAL-AGENCY Q STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUKrYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(9%)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓Om bhSCNe O 1 SELr-i%uRED O 2 GUARANTEE O 5 INSURANCE O A SURETY BOND <br /> O 5 LETTER OF CREDIT a EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo II is c d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. X11. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORAECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNERS TITLE DATE ON KDAYNEAR <br /> / qy <br /> LOCAL AGENCY USE ONLY Gl <br /> COUNTY# JURISDICTIO • FkciLrry a• <br /> 14 a- <br /> LOCATq CODE -OP NAL CENSUS TRACT# -OPTIONAL f SUPVISOR-DISTRICT CODE -OPTIONAL -_ - <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA 13931 <br />