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-`epyn � <br /> STATE OF CALIFORNIA �� 'o <br /> STATE WATER RESOURCES CONTROL BOARD Wm�' ,�; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 'p <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `•t,.ae"'' <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Et!r7 PERMANENTLY CLOSED SIT <br /> ONE REM Q 2 INTERIM PERMIT F-1 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA DIB F9CILITV E NAM OFOPERATOR <br /> ADDRESS NEARESTCROS59 REET PAPCELaIOPrgNAp <br /> ` i >M o L <br /> 1111 AME STATE 21P CODE ITE PH NE a WITH AREA CODE <br /> /lam CA <br /> L <br /> ✓ BOX LJ�I CORPORATION INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' (]STATE-AGENCY' I3 FEDERAL-AGENCY' <br /> TO INDICATE / - DISTRICTS' <br /> N inner of UST Is a public agency,complete the following:narne ol Supameor of dNlebn,section.w onice which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATIONRESERVATION <br /> Q 2 DISTRIBUTOR 0 ✓ IF INDIAN a OF TANKS AT SITE I E.P.A. I.D.a(optional) <br /> 0 3 FARM O 4 PROCESSOR EX 5 OTHER OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> t a09 2) CIED <br /> TS: NAME ILAST. IRS PHONE O WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> L L Zl Ck sl - '4 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> L <br /> MAILI GOR STR ET DRESS ✓ bo[bIMbN21 INDIVIDUAL O LOCAL-AGENCY C::]STATE-AGENCY <br /> 0 CORPORATION D PARTNERSHIP D COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY AME STATE ZIP CODE HONEa WITH AREA CODE <br /> CrQ - d <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �✓ bol,to indicate 71 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> IJP CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CI NAME(1 STATE ZIP CODE PHONE#WITH AREA CODE <br /> le <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCI RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bot bintlkNe 1 SELF-INSURED O 2 GUARANTEE D 3 INSURANCE O A SURETY BOND <br /> D 5 LETTER OF CREDT Q 6 EXEMPTION 99 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.O I.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PR INTEDB SI/GINED) OWNER'S TITLE DATE? MONTWDDAAYNEAR <br /> LOCA AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY t -r' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CGDE -OPTIONAL <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 /> FORMA(393) <br /> OWNER MUST FILE THIS FIWITH THE LOCAL AGENCY IMPLEMENTING THE UNDER(jWD STORAGE TANK REGULATIONS <br /> FORl1R13Ai17 <br />