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• STATE OF CALIFORNIA • "e"pO `0s°o <br /> STATE WATER RESOURCES CONTROL BOARD ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A v o <br /> COMPLETE THIS FORM FOR EACH F LIfY/SITE c"��•°" <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMA ED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE y <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) V <br /> DBA OR FACILITY N I,. ' NAME OF OPERATOR <br /> 7)G ALO 1 / <br /> ADDRESS NEAREST CROSS STREET P(29 <br /> ARCELa(OPfIONAL) <br /> CITY NAME STATE ZIP C205,0,./ SITE PHONE WITH AREA CODE <br /> CA / <br /> ✓ Box <br /> TOINDICATE D CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY AGENCY 0 STATE AGENCY 0 FEDERALAGENCY <br /> DISTflICTS 0 <br /> TYPE OF BUSINESS ❑ T GAS STATION F—] 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> ❑ 3 FARM 4 PROCESSOR = 5 OTHER 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ INDIVIDUAL <br /> box biMkala 0 LOCADAGENCY O STATE-AGENCY <br /> 0 <br /> CITU NAME CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> STATE ZIP CODE 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 biMkate INDIVIDUAL 0 LOCAL-AGENCY E-1 STATE AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP ] COUNTYAGENCY 0 FEDERALAGENCY <br /> CITU 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) HO 14_14 -[_] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biiMicate I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> 0 O<SUREN <br /> 5 LETTER OF CREDIT BONG <br /> O 6 EXEMPTION D 59 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.❑ I.❑ 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 A SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY i <br /> LOCATION O Op�(, / —L�� <br /> TION L (CENSUS TRACT -OPTIONAL 'SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FOR MUST BE ACCOMPANIED BY AT AST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE IN ON ONLY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FOfl0033AR6 <br />