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0 • �peOVe F.S <br /> STATE OF CALIFORNIA °O*. <br /> / STATE WATER RESOURCES CONTROL BOARD <br /> v UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ye <br /> COMPLETE THIS FORM FOR EAC ACILRY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY D SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME — NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> a <br /> CITY NAME / STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> C k CA <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION #OF TANKS AT SITE E.P.A. L D.#(optimal) <br /> O 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) PHONE 9 WITH AREA CODE <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 STREETADDRESS ✓ box bIndicate O INDIVIDUAL O LOCAL AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP [–I COUNTY-AGENCY 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 biMkale [–I INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION O PARTNERSHIP 0 COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME- STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF ALI N T STORAGE FEE COUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 nQ j 1 7 L <br /> V. PETROLEUM US PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ box binGicM. L-1 I SELF INSURED El 2 GUARANTEE 0 3 INSURANCE 4 <br /> Ez SURETY BOND <br /> 5 LETTEROFCREDIT = 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: 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# P/ALJ P3 <br /> LOCATIONCODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT� 100E -0PTIONAL <br /> 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNDSTANK REGULATIONS T <br /> 0 <br /> ,, �? 9�FOfl0037A P6 <br />