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• • abouR es <br /> STATE OF CALIFORNIA APP cO� <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> AMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F__] 1 NEW PERMIT 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> s <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA9cILITY NAME 1 I /n �vlCe� <br /> ADDAE S NAME OF OPERATOR <br /> f/�� LNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1 �vr, Geo <br /> CITY NAME" STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> z_D CA <br /> ✓ Box <br /> TO INDICATE CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN #OF TANK$AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION /`i/J^^— <br /> 3 FARM a 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) <br /> PHONE a WITH AREA GODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE;#WITH REA CO <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box ID Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY E=1 STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP COUNTY-AGENCY Q 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 -IQ $ 2 j 4'Ste' memo -& o-pnit <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box to indicate O 1 SELF-INSURED 2 ARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT EV6 EXEMPTION = 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unlessW6 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.LvfII.1= 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 MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# —"- ! JURISDICTION# FACILITY# D 1 <br /> /-,5/1 EETI1 t <br /> LOCATION COQq ONAL CENSUS T5ACj# -OPTIONA iSUPVISOR-DISTRICT CODE -OPTIONAL V I— 1 J <br /> 24 9 <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 A(5-91) FOR/00 <br /> 033A-5 (�_ <br />