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1 <br /> • • PL60JVCe <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD m <br /> 1 UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A e <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION Z PERMANENTLY CLOSED S E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D FACILI AVE NAME OFOPERATOR W <br /> A DRE • NEAR TCROSSST ET PARCEL#(OPTIONAL) <br /> CITY STATE ZIP �Z y5 SITE PHO l'�I�gE-7 <br /> CA ch/G/N// _Ibl / `/moi~✓G <br /> TOO v BOX INDICATE CORPORATION INDIVIDUrF--1ERSHIP = LOCALAGENCY COUNTY AGENCY STATE AGENCY O FEDERALAGENCV <br /> DISTRICTS <br /> TVPEOF BUSINESS ❑ 1GA5 STATION ❑ 2DISTRIBUTOR ❑ RESEF INDIAN #OFTANK AT SITE E.P.A. I.D.#(oplimal) <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ADD SS ✓ box nindkate 0 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ box toindkale INDIVIDUAL LL] LOCAL-AGENCY STATE AGENCY <br /> l�CORPORATION PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HO 14141-L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE CO ETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate = I SELF-INSURED W GUARANTEE [-I3 INSURANCE I� 4 SURETY BOND <br /> U 5 LETTEROFCREDIT 6 EXEMPTION F] W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unlesszx I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ III.❑ <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 DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY It <br /> q -LL 1 <br /> LOCATIONOPTIONAL CENSU�j�4C�##- O� SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETANK REGULATIONS <br /> FOR009AR6 <br />