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• ' • STATE OF CALIFORNIA • <br /> STATE WATER RESOURCES CONTROL BOARD iyd'xM1 Y•1'e c +o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE .A yin <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITf�l�� n5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ # AMENDED PERMIT u 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACI TY AVE Y NAME OF OPERATOR <br /> ADDRESS a� NEA E CROSS STREET PARCELH(OPTIONALI <br /> � J <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA75,;2 ,0,6 <br /> TO <br /> Box E:1 CORPORATION Q INDIVIDUAL O PARTNERSHIP (]LOCAL-AGENCY O COUNTY-AGENCY' Q STATE-AGENCY' QFEDERAL-AGENCY' <br /> •H ownarol UST b epub6c agency.campkb the blbwng name d supervisord Lrvb4n,section DISTRICTS <br /> oroHca whits apereles the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A I.D.#(op#anep <br /> ❑ 3 FARM ❑ # PROCESSOR IX 5 OTHER O OR RESERVATION <br /> "`I✓✓' TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGE ONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,RRST) PHONE#WITH AREA CODE DAYS: NAME( ,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIG : NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLET <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to incimle Q INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> D <br /> CITY NAME CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE p WITH ARFACODE <br /> III. TANK OWNER INFORMATION-(MU BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bad o Indicate [] INDIVIDUAL O LOCAL-AGENCY ESTATE-AGENCY <br /> O CORPORATION Q 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)322-9669 if questions arise. <br /> TY(TK) HQ F4-[4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 1p iWk:ate 0 1 SELF-INSURED 0 2 GUARANTEE E:1 3 INSURANCE O H SURETYBOND Q 5 LETEROFCRm1T 0 6 EXEMPTION (]T STATE FUND <br /> I18STATE FUND BCHIEF FINANCIAL OFFICER LETTER Q9STATE FUND&CERTIFICATE OFDEPOSIT ED 10 LOCAL GOVT.MECHANISM O89OTHER <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.❑ I.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE,IS TRUE AND CORRECT <br /> TANKOWNER'SNAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY T U oZ 3 7 a 6 <br /> COUNTY# JURISDICTION It FACILITY# <br /> � 3 • i <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR•DISTRICT CODE -OP /ONAL <br /> l/0 <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(6-95) OWNER MUST FILE THIS FORMW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS <br /> 13 - � 7 �°- <br />