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STATE OF CALIFORNIA 4 s <br /> • STATE WATER RESOURCES CONTROL BOARD 3 ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A p��� „ y <br /> �'c i.uh N"• <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 'PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATDR <br /> AA <br /> i ve/—j:;� I PARCEL r(OPTIONAL) <br /> ADDRESS <br /> NEAREST CROSS STREET <br /> CITY NAME STATE ZIP ODE SITE PHONE a WITH AREA CODE <br /> c � �I CA - � I 2 � <br /> TO INDIICCATE ©CORPORATION NDIVIDUAI PARTNERSHIP 0 LOCAL-AGENCY R COUNTY-AGENCY � STA7E-AGENCV [] Ft DERAt•AGENGY <br /> TYPE OF BUSINESS 1 GAS STATION 2 O STRIBUTOR CTS <br /> =TRUST <br /> R OF TANKS AT SITE E.P.A. !.D.�+(optional) <br /> 3 FARM 4 PROCESSOR = 5 OTHER <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME{LAST,FIRST) <br /> 1 i - G - (J <br /> NIGH S: NAME(LAST, t�> PHONE a WITH AREA CODE NIGHTS: NAME;LAST,FIRST} <br /> L-9JJ7I ' <br /> ll, PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATkON <br /> NAME <br /> DR I S ✓ boxtoindku� <br /> !RAILING OR STREET ADDRESS � INDIVIDUAL � LOCAL�AGENCY � STATE-AGENCY <br /> l r ©CORPORATION I] PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> r STATE ZIP CODE PHONE x WITH AREA CODE <br /> CITY NAME <br /> lll. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR_TRE ADDRESS ✓ box m indicate INDIVIDUAL [ LOCAL-AGENCY 0STATE-AGENCY <br /> CORPORATION PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CETY NAME STATE ZIP CODE PHONE M 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 4 -FF ? 7. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 1a indkale = 1 SELF-INSURED Q 2 GUARANTEE = 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION Q 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 13ILLING: 1. <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) APPLICANTS TITLE BATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# ;/ J� 1 ry <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> F <br /> FORM A{5-911 <br />