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• eioun ea <br /> STATE OF CALIFORNIA .r �. <br /> STATE WATER RESOURCES CONTROL BOARD 3 m <br /> \� T( UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� �s <br /> ��(��Oe M��-O <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [�] 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY <br /> NAME E NAMEOFOPERATOR <br /> \ V <br /> ADDRESSD NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> cl!5 to <br /> CITY NA STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> CA s a ;'— <br /> I/ Box <br /> TO INDICATE CORPORATION O INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY D COUNTY-AGENCY O STATE AGENCY l= FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional/ <br /> RESERVATION <br /> 3 FARM 0 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) PHONE WITH <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMf c CARE OF ADDRESS INFORMATION <br /> 4 / S <br /> MAI G OR STRE ADDRESS Q r ✓ dommieate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> t b, Lj 0 5 0 0 CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY O FEDERAL-AGENCY <br /> CITY NAME ^ STATE ZIP CODE P �# ITH AREA CQDE <br /> III. TANK DOWNER INFORMATION•(MUST BE COMPLETED) (0/ <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bintlbate INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 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 14 [4]-CJF= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicateI SELF-INSURED =2 GUARANTEE 3 INSURANCE l]4 SURETY BOND <br /> O 5 LETTER OF CREDIT O 6 EXEMPTION e3 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.0 U. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY , <br /> COUNTY It JURISDICTION It FACILITY# <br /> I <br /> 1— <br /> - - - -- - -- <br /> LOCATIONCODE � PTIONAL CENSUSTRACT# -OPTION SUPVISOR-DISTRICT CODE OPTIONAL <br /> THIS F011M MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM Ane-9u FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033AR6 <br />