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C <br /> eE9ooa e <br /> STATE OF CALIFORNIA o t <br /> STATE WATER RESOURCES CONTROL BOARD' o <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 0 t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION IV <br /> 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA AFACILITY NAM / NAME F OPERATOR <br /> AD GG 5 argN A ESTC OSS EEL PARCEL NIOPTIONAL) <br /> ne. A,"," <br /> C N STATE ZIP G � SITE PHONE WITH AREA CODE <br /> CA (6� <br /> ✓ BOX <br /> TOINDICATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP E::] LOCAL-AGENCY COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS,AT SITE E.P.A. 1.D.S(optional) <br /> OR <br /> RESERVATION / <br /> 3 FARM 4 PROCESSOR = 5 OTHER TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD RESS ✓ bot bindicaN INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME 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- ✓boa blWicata INDIVIDUAL D LOCAL-AGENCY I] STATE-AGENCY <br /> CORPORATION D PARTNERSHIP COUNTY-AGENCY 0 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) HO AN <br /> PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box birAkate = 1 SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE 4 SURETYBOND <br /> 5 LETTER OF CREDIT 0 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: 11-1 11.1-1 111.E, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP LI CANT'S NAM E(PR IN TED&S IGNATU RE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COOUNTY# C JURISDICTION# FACILITY# � <br /> PV <br /> LOCATION 0 E IOPTIONAL 10EN5 RACT OPTIONS(. SUPVI R- ISTRICTCOD��I J <br /> -- `G7l E -OPTIONAL - --- - --- <br /> 23. D <br /> THIS FORM MUST BE ACCOMPANIE Y 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 F M WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGEREGULATIONS // <br /> 1 legc+ies)..f 11 Z� Amd Ion f (//� <br />