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7 <br /> • STATE OF CALIFORNIA • peeoun es <br /> P 05 <br /> STATE WATER RESOURCES CONTROL BOARD 3e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> •P sO�N� <br /> __--COMRLETE THIS FORM FOR EAC CILRYISITE - <br /> MARKONLY PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER ANENTLV CLO SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION III ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME / NAMEOF PERATOR <br /> Rei � LL <br /> AD ESS YXIINEAREST ROSS STREET PARCEL#(OPT)ONAO <br /> �il1J/J� <br /> CITY AVE STATEX/ZIPC 7SITE PHONE#WITH AREA CODE <br /> / �a <br /> ✓ X <br /> TO INDI E D CORPORATION O INDIVIDUAL PARTNERSHIP LOAGENCY Q COUNTY-AGENCYSTATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM ROCESSOR RESERVATION <br /> O 5 OTHER O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA EODF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box blMkale O INDIVIDUAL Q LOCALAGENCY QSTATE-AGENCY <br /> D CORPORATION 0 PARTNERSHIP L-1 COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CDOE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box b Indicate INDIVIDUAL E-1LOCAL-AGENCY0STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP = 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 L4 4] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate L-1 I SELF-INSURED L:1 2 GUARANTEE [] 3 INSURANCE x SURETY BOND <br /> D 5 LETTEROFCREDIT L-1 6 EXEMPTION IN 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.E] III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP LICANT'S NAM E(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAVNEAR <br /> LOCAL AGENCY USE ONLY <br /> CI I # / 4 —]v JU ISDICTION# ITY# <br /> I <br /> _._ t�LOCATIONCODE - IO L CEN US TRACT# OPTIONAL SUPVISOR-DISTRICT DE - NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS T GE OF SITE I ATION ONLY. <br /> FORM A(12-e1) FILE THIS FORM WrTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS L� <br /> c . Sa'i')— a 0 �'x'1FOR0033A.R6 <br />