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STATE OF CALIFORNIA e. <br /> STATE WATER RESOURCES CONTROL BOARD 6 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> 'o v0 ti <br /> OXY e <br /> COMPLETE THIS FORM FOR EACH F (SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME NAME FOPERATOR O <br /> W - A M t <br /> MXjADDRESS HA <br /> 7 NEAREST CROSS STREET PARCELp(OPTIONAp <br /> CITY NAME STATE ZIP CO E SITE PHONE#WITH AREA CODE <br /> CA <br /> I/ BOX <br /> TOINDICATE O CORPORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY E-1 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS f�F 1 GAS STATION Q 2 DISTRIBUTOR O */ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opllmal) <br /> 1� RESERVATION <br /> 3 FARM4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FI S HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMEPHA 5KLJ�TREETCARE OF ADDRESS INFORMATION <br /> MAILING ORSADDRESS Y' box mindIcau 0INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> �M},7♦rr D CORPORATION D PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAyfE - STAT ZIP OQE PHONE#WITH AREA CODE <br /> -6LA 6A r3,36 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAE PFOWN R5-1r, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 10indicale INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP D COUNTY-AGENCY D 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 [4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bind; t I SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT O 6 EXEMPTION N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. I.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# �A � NLJyZ <br /> N � <br /> LOCATION CODE -OPTI;NAL CENSUS TRACT# -OPT�� SUPVISOR-DIBTRICT CODE -OPTIONAL '�� <br /> THIS FORM MUST BEACCOMPANIEDBY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) <br /> FOg0033A5 <br />