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• • cyoun � <br /> STATE OF CALIFORNIA ^� °O, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A `� "sse <br /> °4,ron X`X <br /> COMPLETE THIS FORM FOR EAC CILrTY/SITE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) S <br /> DBAOR CILITYNAME NAME OF OPERATOR <br /> en <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPrIONAL) <br /> CITY NAME p S7 CA ZIP CODE a D SITE PHONE#WITH AREA CO E <br /> TO INDICATE O CORPORATION EZINDIVOUAL O PARTNERSHIP 0 LOCAL-AGENCY Q COUNrY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(opflanal) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION / <br /> O O 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 /> e-,- d -Y S <br /> NIGHTS: NAME(LAS IRSPHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> I PHONE#WITH AREA CC E <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ,^ /T— CARE OF ADDRESS INFORMATION <br /> eI 1 <br /> MAILING RSTREET ADDRESS ✓ box blMicate D INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkaW ED INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP = COUNTY-AGENCY Q 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 Ks 0 3 a a a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0 Micale 0 1 SELF-INSURED 0 2S3UARANTEE 3 INSURANCE 4 SURETY BONG <br /> O5 LETTER OF CREDIT 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. II 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&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAV/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION <br /> = I-t'? �y <br /> Y <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o a <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(591) /;L FOR0033A5 <br /> • /V • 7 7 �21 `� <br />