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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> (2,11. COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT E] 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAFAC ITYNAM NAMEOF ERO <br /> ADD / �� NEABF6T <br /> CCROOSSSSSTREEET PARCEL#(OPFIONAL) <br /> U// w <br /> CI A STATE 21PC SITE PHONE#WITH AREA CODE <br /> CA <br /> 520 3 <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP DISTRICTS COUNTY AGENCY OSTATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS F GAS STATION O 2 DISTRIBUTOR -/ <br /> IF INDIAN #OF TAN AT SITE E.P.A. I.D.#(optional) <br /> O 3 FARM O 4 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE N 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 bNAbm INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> 1�CORPORATION 0 PARTNERSHIP D COUNTY-AGENCY 0 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 x,INkaw INDIVIDUAL LOCAL-AGENCY (] STATE AGENCY <br /> =CORPORATION O PARTNERSHIP COUNTY-AGENCY 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 144�- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMP ED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkale 1 SELF INSURED 0 2 RANTEE = 3 1NSURANCE O A SURETY BOND <br /> O 5 LETTEROFCREDIT EXEMPTION O 99 OTHER <br /> 771 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O 11.0 U.0 <br /> THIS FORM NAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CNTV# <br /> 91 URIISDICTIIOON# FACILITY## <br /> / L—L1� �LyLI--L_-Flf/� <br /> 1 <br /> NLS! -- - <br /> LOCATIONCODE�O TIONAL CENSUSTRACT# -OPTIONAL �ryD 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 0 E I MATION ONL . <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGU <br /> FORD <br /> `se 'A>✓ <br />