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STATE OF CALIFORNIA • •`°c c c <br /> STATE WATER RESOURCES CONTROL BOARD -r��L� <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ra <br /> v a Y/ , <br /> O <br /> COMPLETE THIS FORM FOR EACH F ILRY/SITE <br /> °- ,.oy <br /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION RM ENTL CLOSED SITE <br /> ONE REM IN PERMIT A AMENDED PERMIT a TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SIT INFORMATION&ADDRESS•(MUST BE MPLETED) <br /> DBA OR FACILITY NAME <br /> NAME Of OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL Y(OPTIDNAU <br /> CITY NAME STATE ZIP CODES SITE RHO WITH EA CO <br /> - M,� <br /> TO INDCATE C7 CORPORATION (]INDIVIDUAL 0 PARTNERSHIP O LOCALAGENCY 0 COUNrY.AGENCV <br /> OISTRICTS 0 STATE-AGENCY 0 FEDEHALAGENCY <br /> TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN Y OF TANKS AT SITE I E.P.A- I.D.Y(optional! <br /> = RESERVATION <br /> OR I <br /> 0 3 FARM Q A PROCESSOR Q 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE Y WITH AREA COOS GAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE 6 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> P4 Y <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF AOORE55 INFORMATION <br /> MAILNG OR STREET ADDRESS ✓ W6bIWKv6 O INONDUAL 0 LOCAbAGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDEML.AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Y WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) , <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ 60 DYtlkN6 O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY 0 FEOERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 6 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ 5m Din&m 0 1 SELF-INSURED 0 2 GUARANTEE Q 7 E 0 /SURETY BONG <br /> D 5 LETTEROFCREDT 0 6 EXEMPTION 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 INOICATING WHICH A80VE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLNG: I.= It. IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR NTED A SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY �z <br /> COUNTY R ° RISOICTION A FACILITY Y <br /> LOCATION CODE -OPTIONAL T6 -OPT70NAL SUPVISOR- (STRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• ORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) <br /> FOA=A 5 <br /> i � <br />