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}OUR <br /> STATE OF CALIFORNIA .e. ��� <br /> STATE WATER RESOURCES CONTROL BOARD s` Y a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> e �Y/ <br /> UnY" <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT r_1 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE (31 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> CC)JU <br /> ADDRESS NEARESTCROSS PARCEL a(OPTIONAL) <br /> CITY NAME STATE ZIP ODE SITE PHONE#WITH AREA CODE <br /> CA 2 <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP D LOCAL-AGENCY D CO ENCY O STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR 0 q SERVATION A OF TANKS AT SITE E.P.A. I.D.#(aptbnal) <br /> Q 3 FARM O 6 PROCESSOR [=] 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) PHQNP*WITH AREA mnF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS _ ✓ b blmA L�] INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> - - ---. O C po = PARTNERSHIP D COUNTY-AGENCY =FEDERALAGENCY <br /> CITY NAME STATE ZIP CO PHONE 8 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> Okp <br /> MAILING OR STREET ADDRESS ✓ box biMkak, 0INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Ze CORPORATION l= PARTNERSHIP COUNTYAGENCY 0 FEDERALAGENCY <br /> CITY NAME I STATE ZIP CODEf PHONE#WITH AREA CODE <br /> I . ARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER--Call(916)323-9555 if questions arise. <br /> TY(TK) 4 <br /> V. PETROLEUM UST FINANCIAL RESPON - GST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkaN F—I 1 SELF-INSURED Q 2 GUARANTEE O 3 INSURANCE [_]4 SUflETY SONO <br /> D 5 LETTER OF CREDT 6 EXEMPTION D 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 BO%INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O 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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION# FACILITY# <br /> L MLI)NZS 121510 1—:41 14/�r <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 320 Z -2-/Z57/q2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) Lip 7/%2 FORMA5 <br />