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eooua as <br /> STATE OF CALIFORNIA ^+ <br /> STATE WATER RESOURCES CONTROL BOARD i° �' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A �� vo <br /> C�t,�O„N,� <br /> COMPLETETHIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Lj 2 INTERIM PERMIT E:1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME / NAME OF OPERATOR <br /> ADDRESS r('/v/H NEAREST CROSS STREET PARCEL#IOPIONAU <br /> CITY NA A-� STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> J CA 6' <br /> I/ BOX <br /> TO INDCATE D CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY n COUNTY-AGENCY I1 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR / 0 RESERVATION F INDIAN <br /> DD #OF TANKS AT SITE E.P.A. I.D.#Wfimal) <br /> 3 FARM O 4 PROCESSOR L fffY OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO ACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) PHnNP 9 WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CQnF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM�G.6 S 77CARE OF ADDRESS INFORMATION <br /> i <br /> m_AuNd­oR-STREET ADDRESS ✓ box bintlkab ED INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> D �d E <br /> CORPORATION 1 PARTNERSHIP O COUNrV-AGENCY I1 FEDERALAGENCY <br /> CITY NAME— STATE ZIP CODE ON WIT EACODE <br /> �5 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME/O)F OWNE/R CARE OF ADDRESS INFORMATION <br /> G/ <br /> MAIL( ORSTREET DRESS ✓ box bilbicaW E-1INDIVIDUALO LOCAL-AGENCY E-1 STATE-AGENCY <br /> • b D Z O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE WITHAAEE <br /> A <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. 7C� <br /> TY(TK) HQ 4 4 -� 'l <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box rointlicale O I SELF INSURED —_ 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDIT Ci 6 EXEMPTION N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICT ION# FACILITY# w 7 <br /> LOCATION CODE OPTIONAL (CENSUS TRACT# -OPTIONAL <br /> � SUPVIS R-DISTRICT CODE -OPTIONAL <br /> qq 3 a F.-. �9 <br /> THIS F RM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFO ATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FOR0033AR6 <br />