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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD d� m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s _ , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE '� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �- <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMb p NA OF OPERATOR 2� yL <br /> I r U 2 f, -✓ r µ{SL, 1—d / /CJ �PLGn9�../ <br /> ADDRESS " NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ,,,.c I I PV r c <br /> CITY NAME.. STATE ZIP CODE SITE PHONE p WITH AREA CODE <br /> CA <br /> ✓ BOX CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'II omarrof UST Is a public agency,complete the fol&xT.nems of supenisarcf dmision,section or office Mich operates the UST <br /> DAN <br /> TYPE OF BUSINESS . 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ pE EIRVATION NOF TANKS AT SITE E.P.A I.D.k(optional) <br /> O 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(I-AST.FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE k WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS V, box to bxfmale INDIVIDUALLOCAL-AGENCY STATEAGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxtohdcate INDIVIDUAL O LOCAL-AGENCY STATEAGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE k WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ KE-I 01,; 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 I SELF-INSURED 0 2 GUARANTEE l=3 INSURANCE 0 4 SURETY BOND 0 5 LETTEROFCREDIT 0 6 EXEMPTION 0 7 STATE FUND <br /> 06 STATE FUND&CHIEF FINANCIAL OFRCER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM 0 0OTHER <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.❑ it.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION N FACILITY If <br /> mL�L7L- <br /> LOCATION CODE OP77ONAL CENSUSTRACTN -OPTIONAL � 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 OF SITE INFORMATION ONLY. <br /> FORM q(6-95) OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOTORAGE TANK REGULATIONS <br />