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,., <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ^o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR E!4 FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM n 2 INTERIM PERMIT n 4 AMENDED PER a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME - NAME OF OPERATOR <br /> ADDp U)FASS NEARESTFRO STREET I PARCELJ(OPrpNAL) <br /> CITY NAME STATE•/C/• ZIP DE G,C-•/`//•_ SITE PHONE.WITH AREA CODE <br /> CA 5 <br /> BOX <br /> TO INDICATE E71 CORPORATION Q INDIVIDUAL 0 PARTNERSHIP 0 LOCAL AGENCY O COUNTY-AGENCY STATE-AGENCY l=1 FEDERALAGENCY <br /> OSTRICTS <br /> TYPE OF BUSINESS 0 L (EAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D..(aplionap <br /> Q 3 FARM 4 PROCESSOR RESERVATION <br /> 5 OTHER OR TRUST LANDS <br /> Ei(ERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FI T) PHONE.WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA COD <br /> NIGHTS: NAME(LAST,FIRS PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE I WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGOR STREETADORESS ✓bo "kb "INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 771 PARTNERSHIP 17:3 COUNTY-AGENCY Q FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE.WITH AREA CODE <br /> III. TANK OWNER INFORMATI (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box biMkale = INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> ED CORPORATION I= PARTNERSHIP Q COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE.WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STOR GE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 14147-[:]:j <br /> V. PETROLEUM UST FINANCIAL RESPONSIBIL Y-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkaN = I SELF-INSURED [-12 GUARANTEE 9 INSURANCE 0 4 SURETY BOND <br /> E=1 5 LETTER OF CREDIT =6 EXEMPTION I—] 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.O II.O III.0 <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 a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# J.UW&ENCFI6NNt CG• FACILITY# <br /> LOCATION CODE -OPTIONAL <br /> CENSUS TRACT. -OP AL SUPVISOR DISTRICT CODETIONAL <br /> - <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 /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK <br /> REGULATIONS <br /> /�f Q��-7 L✓J <br /> � CJ !1(/— iV D <br />