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• o " < <br /> c <br /> STATE OF CALIFORNIA �'^ <br /> STATE WATER RESOURCES CONTROL BOARD ;� �` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w � ": <br /> c .:ay� � o <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 5/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACIL pIaME NAME OF OPERATOR , 1 <br /> 1cJ n" N <br /> AODRE 6.I/L/1/ NEARES ROSS STREET PARCELx(OPfIONAq <br /> / 0 orr,�an moa d <br /> CIN NAME„ / STATE ZIP CO4�7ZDq SITE PHONE#WITH AREA CODE <br /> ✓6 CA <br /> TI/ Boox CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> / IF INDIAN x OF TANKS A ITE E.P.A. I.D.#(optimal) <br /> O 3 FARM 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 /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0WkM O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY 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 bivokale INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNrY.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) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkale D I SELF-INSURED Q rUARANTEE 0 3 INSURANCE 0 d SURETY BOND <br /> D 5 LETTEROFCREDIT EV6 EXEMPTION O W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ 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 MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 7 JURISDICTION# FACILITY# <br /> Sy <br /> P141-T5 9/ � o m& <br /> LOCATION CODE -O$j/rL CENSUS TRACT# •OPT N L SUZS2-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) FORD033A 5 <br /> 0 A4$/ <br />