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,.�6OUR C C <br /> STATE OF CALIFORNIA <br /> P <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION P RMANENT Y CLOSED ITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE r <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAPFACILITYME NAME OF OPERATOR <br /> T <br /> ADES� D-7 � r r � NEAREST CROSS STREET PARCELp(OPfIONAL) <br /> CITY NAME � I STATE ZIP C4�� � SITE P�E#WITH AREA CODE <br /> S CA 10 N <br /> T0INDIICCATE l�CORPORATlpN Q INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY L COUNTY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME LAST,FIRST) PH NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> a 3- <br /> S: N E;LAST,FIRST) PHONE#VQITIA AFIEA CODE NIGHTS: NAME)LAST,FIRST) <br /> sa144k_X_1_ PHONE#WITH&3 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMEJ/ter � � CARE OF ADDRESS INFORMATION <br /> MAILINGR STREET ADDRESS ✓ box loindicate INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> F CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE O PHO WI f{AREA CODE <br /> .. �c <br /> rpLo 63 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINGLkQ.STREETADDRESS ✓ boxioindicale INDIVIDUAL Q LOCAL-AGENCY © STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME (" STAT ZIP WOE PHONE#WITH AREA CODE <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(918)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxmindicate 0 1 SELF-INSURED [] 2 GUARANTEE 0!3.! URANCE 4 SURETYBOND <br /> 0 5 LETTER CF CREDIT (]6 EXEMPTION [ .t9 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 NOTIFVCATIONS AND BILLING: L[::] II. Ill. <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) APPLICANT'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY f (] <br /> COUNTY# JURISDICTION# FACILITY# <br /> 10 10 <br /> LOCATION CODE -OPTIONAL CENSUS TR CT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> © 3 3 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE FORM�N ONLY. <br /> FORM A(5-91)\�\ 3 r / !Q FOROOS3A-5 <br />