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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD € ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ,.onnn <br /> COMPLETE THIS FORM FOR EACH FACILrrYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION FK 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R ACI TY AMIf NAME OF OPERATOR <br /> _A � /r - / NE STCROSS6TREET PARCEL N(OPrIONAL) <br /> ! CI �l'•./Gn/�) "`/� STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> 1 CA JAZ <br /> T I/ Box <br /> NDICATE E=;CORPORATION E-1 INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY O COUNTY AGENCY E:1 STATE AGENCY E:j FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ qES IF INDIOIAN N #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS •(/f <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHnNP*WITH AREA COPP <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET-ADDRESS ✓ box b indicate INDIVIDUAL O LOCAL AGENCY [__1 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNrY AGENCY [7 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• ✓ bor to micate D INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY <br /> O CORPORATION D PARTNERSHIP L] COUNTY-AGENCY L-1 FEDERAL-AGENCY <br /> CITY NAME' - STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION <br /> , UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 147-41'D]Zj� �=1-� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPL ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to lnekate = 1 SELF INSURED O I ARANTEE I� 3 INSURANCE O 4 SURETY BOND <br /> D 5 LETTEROFCREDIT EXEMPTION = N 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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# / JURISDICr #TION FACILITY It <br /> LO(:ATIO D E OPAL T _ �✓ �/ i�_-._J� <br /> BYICENSJJ 1CTj]��P'ZIONAL SUPVISORRM- )RICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST((1))OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SIT RMATI ONLY. <br /> FORM A(12 e1) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATI <br /> • � FOR00]]Agfi <br />