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STATE OF CALIFORNIA .p °`� <br /> STATE WATER RESOURCES CONTROL BOARD ;��,� ,u <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> C��In°n Nin <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION F-_] 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC1jW NNAME NAME OF OPERAT R .Z <br /> J 0 <br /> ESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1 <br /> CITY AME 0 STATE Z � ® SITE PHONE.(WITH AREA CODE <br /> TOINDIICCATECORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL 0 COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS X 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN 4 OF TANKS AT SITE I E.P.A. 1.D.It(optimal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAV : NAM (LAST,FI PHONEa WITH AREA CODE DAYS: NA ME(LA ST,FIR ST) <br /> ao <br /> NIGHTS: NAME(L T,FIRST) PHON A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 1 1 14 PHONE It WITH AREA CODE <br /> fl. PROPERTY OWNER INFORMA ON• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box 0lnAKaN L-1 INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> 0 CORPORATION I= PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST B COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ bar toindkate O INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP COUNTY AGENCY D FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE 9 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCO NT NUMBER-Call(916)323-9555 if questions arise. <br /> 1 <br /> TY(TK) HQ 41-F� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box loinbicala I SELF-INSURED I=2 GUARANTEE 0 3 INSURANCE 4 SUREN SONO <br /> C 5 LETTEROFCREDIT E-1 6 EXEMPTION L-1 93 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.❑ II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY o1. <br /> COUNTYY LTIt JURISDICTION If FA�CIILI�TIr <br /> �`j�(f� <br /> L 61 <br /> LOCATION <br /> "�t�. 1 <br /> LOCATION CCOODE OPTIONAL (CENSUS TZTA -OPyQyflL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM,'BdB,,'-UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS F0'eMSff1L1ULLW4L.AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> J yV q� 721lease FOf10033A fl6 <br /> } i ss � <br />