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STATE OF CALIFORNIA • '0So"��� <br /> 5� , <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE � i,� <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED M SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT '� TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION a ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS N REST CROSS STREET PARCEL#(OPTIONAL) <br /> w <br /> Zv L Trol �Ivzc 1 <br /> STATEZIP CODE ITE PHONE#WITH AREA CODE <br /> CA 9 ?J <br /> ✓BoxCORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY CGUNTY-AGENCY' STATE-AGENCY' <br /> TO INDICATE T DISTRICTS FEDERAL-AGENCY' <br /> lownerol UST'aa Wblkageray,mmpletetheloMwing:Tacna of supery orol Rrvuian,Swim oroKce which operates the UST <br /> TYPE OF BUSINESS © 1 GAS STATION ✓2 DISTRIBUTOR DIAN #OFTANKS AT SITE E.P.A. I.D.# <br /> ❑ ❑ RES <br /> ERVATIONIFIN (pPllwreq <br /> ❑ 3 FARM ❑ d PROCESSOR ❑ 5 OTHER OR TRUST LANDS 3. <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NA E(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ZoNIGHTS: NAME(LAST,FI PHONE' WITH AREA CODE NIGHTS: NAME(LAST,FlRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NnCARE OF ADDRESS INFORMATION <br /> T ' <br /> MAILING OR EETADDRESS v1boxloidf a Il INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 71'!fI (I CORPORATION Ej PARINERSHIP Q COUNTY'-AGENCY Q FEDERAL-AGFNCY <br /> CITY NAME / STATE 21P CODE <br /> i 1 HONEp I AREA CODE <br /> 7�, 5 , L <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> N OFOWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box londimte Q INDIVIDUAL LOCAL-AGENCY E--1 STATE-AGENCY <br /> 7f (/ Q CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COOgE P ONEp)1AR ACODE <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ K4-]- J J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 I SELF-INSURED ,L—I 2 GUARANTEE E--]3 INSURANCE L-1 4 SURETYBOND 5 tETTEROFCREDIT O 6 EXEMPTION =T STATE FUND <br /> I�8STATE FUND&CHIEF FINANCIAL OFFICER LETrER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM =1 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.❑ 11.❑ III.O <br /> THIS FORM HAS BEEN COMPLETED=PENALTY PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TAIqIWOW/RV: NAME(PRINTED a SIGNATURE) /� TANK OWNE 'S DATE MO TDAY EAR <br /> �2 Z W'/ CI <br /> LOCAL AGENCY USE ONLY �> <br /> COUNTY# JURISDICTION# FACILITY# <br /> 604I I� I JI l <br /> LOCATION CODE-OPTKWAL CENSUS TRACT# -OPTIONAL SUPVISOR-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 /> FORMA(6-95) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUIWORAGE TANK REGULATIONS <br />