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• oe <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ,,nne�x��Oe NDN <br /> COMPLETE THIS FORM FOR EACH F ILtI'YISITE <br /> MARK ONLY 1 NEW PERMIT n 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIE <br /> ONE ITEM 2 INTERIM PERMIT L_ 4 AMENDED PER 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DEAN FACILITY NAME NAMEOFOPERATOR <br /> LIG v� ^ <br /> ADDRESS NEAREST CROSS STREET PARCEL IOPIONAU <br /> CITY NAME STATE ZIP CODE S PH E#WITH AREA CODE <br /> oDr' CA <br /> T NDIICCATE CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTRAGENCV D STATEAGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE OAVS: NAME(LAST,FIRST) <br /> PHONE N WITH AREA rnDE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE*WITH AREA GOT <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> M AILING OR STREETADDRESS ✓box bblEbate 1=1 INDIVIDUAL [-ILOCAL-AGENCY0STATE-AGENCY <br /> 15;4 T D CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME - STAT ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER dAl e- CARE OF ADDRESS INFORMATION <br /> 0 <br /> MAI LINNO OR STgEET ADDRESS//J� ✓ box bindicala 0 INDIVIDUAL 0 LOCAL-AGENCY (�STATE AGENCY <br /> 5� —/ 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STAT ZIIP 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 bindicale I SELF INSURED 0 2 GUARANTEE [-D 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTEROFCREIT 0 6 EXEMPTION 0 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.❑ 11.1= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO RECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# _ <br /> LOCATION CODE OPTIONAL CENSUS RACT#OPTIONAL ISUPVI2�O�R-OISTRI TCODE -OPTIONAL <br /> j�r 17 5b <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION�FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION-ONLY <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> F flfi \„ <br /> �aJ <br />