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STATE OF CALIFORNIA ^rw ... t•. <br /> STATE WATER RESOURCES CONTROL BOARD w4"` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM-A <br /> COMPLETE PHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY Q 1 NEW PERMIT F-13 RENEWAL]PERMIT 5 CHANGE OF INFORMATION EV7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITY NAME I NAME OF OPERATOR <br /> ADD ' If/ JJ/ NEAREST CROSS STREET PARCEL M(OPTIONAL) <br /> Ct LAV <br /> CITY NAYr STATE ZiP CODE SITE PHONE A WITH AREA CODE <br /> rQ CA <br /> TOINDI,tiC T5 Q CORPORATICN Q INDIVIDUAL Q PARTNERSHIP Q.LOCAL-SENCY ©COUN3'Y-AGENCY [] STATE-AGENCY Q FEDERAL-AGENCY. <br /> TYPE OF IuSiNESS Q I GAS STATION Q 2 DISTRIBUTOR Q RESEIRVATDIAN x OF 7 S AT SITE E.P.A. L 0.8(00607al} <br /> Q 3 FARM Q 4 PROCESSOR Q','S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CCOE. DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PY ca WITPA RCA CCffE <br />' f , <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS WFORMATICN <br /> ,NAILING OR STREET ADDRESS ✓ bmt to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> © TON FEDEPALAGENCYCORPORA <br /> CITY NAME STATE71P CODE PHONE 4 WITH AREA CODE <br /> I <br /> Ill, TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF CWNEA CARE OF RODLESS INFORMATION <br /> MAILING OR STREET ADDRESS - ✓ On m indicate © INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> ©CORPORATION Q.PARTNERSHIP © COUNrY•AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) Ha 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COM ETED)-IDENTIFY THE METHOD(S) USED <br /> ✓boc b nd cata © I SELF•lNSURED <br /> =]/GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT CV8 @($MPRON Q 99 OTHER <br /> VI. LEGAL.NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADCRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1, It. 11E• <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE$EST OF MY KNOWLEDGE.1S TRUE AND CORRECT <br /> ,APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTWDAY/YEAR - ;( <br /> LOCAL AGENCY USE ONLY t <br /> COUNTY it JURISDICTION N FACILITY# <br /> LOCATION CODE.• PTIONAL CENSUS TRACT 0 -OP_T.ICNAL SUPVISOR-DISTRSCT CODE -OPTIONAL <br /> VIS (_rJ a LLLrJrrr IPJ . <br /> THIS FORM MUST BE ACCOMPANIED BY AT:LEAST(1)OR MORE PERMIT APPLICATION• FORM $ UNLESS THIS IS A CHANGE OF SMIN ONLY: <br /> FORMA(5.911 <br />