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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> i UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ;e <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE -- <br /> MARK ONLY D r NEW PERMIT 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION 7 PERMAN TLV LOBED SITE <br /> ONE ITEM 2 INTERIM PERMIT 6 AMENDED PERMIT [:] B TEMPORARY SYTE CLOSURE <br /> I. FACILRY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 14 <br /> AODflE55 NEAREST CROSS STREET PARCEL 0(OPTIONAU <br /> j e <br /> 6;9,+A(7-Z iNe <br /> CITY NAME ST v Box CA ZIP COD .3,7� SITE PHONE WITH AREA CODE <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNE HIP Q LOCAL-AGENCY Q COUNrY.AGENCY Q- ATEAGENCY D(y QJFEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS r GAS STATION Q 2 DISTRIBUTOR ' IF INOIAN #O ANKS AT SITE E P.A. I.D.x(mlionai) <br /> RESERVATION <br /> 0 3 FARM Q A PROCESSOR k 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODEGAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PH a WITHAREA CCF <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADORESS ✓ W,0imki Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHP Q COUNTY AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Sox Dm"Ie Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHP Q 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)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 o I I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOO(S) USED <br /> ✓ box 4 J&31* 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE Q/SURETY e0N0 <br /> Q 5 LETTEROFCREDn 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.❑ IL O 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) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISOR.DISTRICT CODE -OPTIONAL <br /> 9-7 i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) FCAOM3A-5 <br />