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i <br /> STATE OF CALIFORNIA • ' <br /> • STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A t �o <br /> 0 <br /> -e Y� <br /> _ LSETBIS FORM FOR EACHFACILITYISITE <br /> MARK ONLY I� 1-NEW PERMIT 7 RENEWAL PERMIT —' <br /> �.J� ❑ � /Y S CHANGE OF INFORMATION ❑ 7 PE NTLY CLO SR <br /> ONE REM 2 INTERIM PERMIT 6 AMENDED PERMIT <br /> ❑ �,8 TEMPORARY SITE CLOSURE ` <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA 0 FACILITY R NAME <br /> Y , NAME OF OPERATOR <br /> / A C-z <br /> ADDRESS NEARESTGROSS STREET PARCEL (OPTIONAL <br /> CITY NAME .✓ <br /> STATE ZIP SITE PHONE A WITH AREA COOE <br /> 2v BOX SCA Z — 7Ju <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL PARTNERSHIP [OCAL-OrTRIGENCy [:1WM <br /> CY.AGENCY <br /> Q STATE-AGENCY Q FEOERAL,LGENCY <br /> TYPE OF BUSINESS E:D1 GAS STATION <br /> i <br /> Q ❑ 2Al❑ ❑ 114 <br /> AN <br /> 3 FARN �ROCESSOR RESERVAT <br /> 5 OTHEfl N s OF TA2NK$AT S <br /> ITE E.P.A. L D.A(gNiorW) <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> L—N <br /> S: NAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> I TS: NAME(LAST,FIRSn PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> 1 0 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREET ADDRESS ✓ Ov biM'rAIA Q INDIVIDUAL LOCAL-AGENCY Q STATE.AGOICy <br /> O CORPORATION Q PARTNERSHIP Q COUNIY.AGENCY Q FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING OR STREET ACORESS• ✓ W.ainarw QINDNOUAL L-1 LOCAL QSTATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q couVYAGENCY Q FEDERALAGENCY <br /> CITY NAMESTATE ZIP CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOO(S) USED <br /> I J eo.a+aNau Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 0 1 SURETY BOND <br /> 0 6 LETTER OFail `;a EXEMPTION Q m OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS legal notification and billing will be sent to the tank owner unless box I Or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND B4LNG: I.❑ II.❑ ITL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> I{ APPLICANTS NAME(PR W TED A SIGNATURE) APPLICANTS TI7LE GATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* r �f , / JURISDICTION* 4— i <br /> # <br /> �LOi:AT10N CODE O *CEN STRA.CTA -OPTIONAL SUPVISOR-DISTRICT O4 r <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS TYkCAANGE OF SITE INFORMATION ONLY. <br /> PORIA A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETANK REGULATIONS <br /> FOR0011AJ16 �\ <br /> 1J <br />