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Oo�R t <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD w i" <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMAS,' <br />�}COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION [—] 7 <br />ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT L] 6 TEMPORARY SITE CLOSURE <br />I PACT( ITVICITF INF(]RMATInN & ADDRESS - (MUST BE COMPLETED) <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - aptlonal <br />DAYS: NAME (LAST, FIRST) PHONE A WITH AREA CODE DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LASr, FIRST) PHONE # WITH AREA CODE NIGHTS: <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMP <br />NAME ( "k, — I ✓' *'4 rC'4 <br />MAILING OR STRgADD <br />CITY NAME <br />III. TANK OWNER INFORMATION - (MUST BE COMPL <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />0 CORPORATION [] PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />STA & ZIP CODE <br />PHONE u WITH AREA CODE <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS ✓ box bIndicate INDIVIDUAL 0 LOCAL -AGENCY [] STATE -AGENCY <br />Q CORPORATION PARTNERSHIP 0 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) HQ [4 141 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate F-1 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE [�771 4 SURETY BOND <br />O 5 LETTEROFCREDIT 6 EXEMPTION 0 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. L-1 it. ��II.El <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& SIGNATURE) I APPLICANTS TITLE DATE MONTH/DAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # jP',4 Tf Z/ <br />LOCATION CODE - OPTIONAL CENSUS TRACT A - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />T� c r m" iei icT or Arrr)"DA I1:n nV AT I FACT 11) nR Mn RF PFRMIT APP( (CATION • FORM B. UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORM A(5-91) All <br />F3A-5 <br />