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r <br /> 40 OVA <br /> STATE OF CALIFORNIA :P "� <br /> STATE WATER RESOURCES CONTROL BOARD ' .; a <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° <br /> COMPLETE THIS FORM FOR EAC FACILITYISITE <br /> MARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Ll2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE :0] <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DB FACILITY NAME NAMEOF OPERATOR <br /> . S <br /> AD 5 / NEAf�EST C SSSTRE T PARCEL a(OPTIONAL) <br /> r Q a- /V/V/ <br /> CI NA STATE ZIP ITE PHONE#WITH AREA COO <br /> CAr�Z03 ZOO 4103- 08 <br /> BOX <br /> TOINOIIC TE O CORPORATION D INDIVIDUAL D PARTNERSHIP DISTRICTS LOCAL-AGENCYD COUNTYAGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN 1101 TANKS AT SITE E.F A. I.D.#(Oplig xl) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR O 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) <br /> PHONEA-WITHABEA-CODF <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindbat# [:11 INDIVIDUAL 0 LOCAL-AGENCY l[7 STATE AGENCY <br /> Q CORPORATION [] PARTNERSHIP O COUNrYAGENCY l= 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 ✓ box blMicaw INDIVIDUAL LOCAL-AGENCY L—I STATE-AGENCY <br /> l�CORPORATION Q 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 4 4 -1 1 [ A_LL] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP TED)—IDENTIFY THE METHOD(S) USED <br /> ✓ baxblMkaW I SELF-INSURED GUARANTEE L-13 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTEROFCREDT 6 EXEMPTION = W 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.❑ IN.❑ <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&SIGNATURE) APPLICANPS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> /Nvvs o I A1471 <br /> LOCATIONCODE OPTIONAL CENSUS TRACT# -OPTINAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 23 - (�O <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(5-91) � F016077A5 <br /> lot <br /> 53v <br />