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£DUA��S <br /> STATE OF CALIFORNIA e A <br /> STATE WATER RESOURCES CONTROL BOARD 3� g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A daD <br /> ZOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PFRI I- 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM _', 2 INTERIM PERMIT a AMENDED Ptndl' 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ACILITY.NN ME C NAME PFRATOR <br /> ADDR s NEA <br /> ST CROS T � PARCELa(OPTIONAL; <br /> CITY NAME STATE ZIP C E, SITE P NEA TH AR A CODE f� <br /> CA <br /> ✓ BOX <br /> TO INDICATE CORPORATION _ INDIV!D_AL PARTNERSHIP LOCAL-AGENCY r COUNTY-AGENCY STATE-AGENCY = FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR I/ IF INDIAN A OF TA SAT SITE E.P.A. I.D.A(optional) <br /> RESERVATION <br /> 3 FARM a PROCESSOR j:: 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P,-LONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA r.()r)r <br /> PHONE 9 WITH AREA C DF <br /> IL PROPERTY OWNER INFORMATION•(MUST BE COMPLETED! <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUALLOCAL-AGENCY <br /> 0STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME V STATE I ZIP CODE PHONE#WITH AREA CODE <br /> i <br /> I I <br /> III. 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 <br /> STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ; ZIP CODE 7Ti3PONE A WITH AREA CODE <br /> I <br /> I <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ .4 4 J- 61 ���1i <br /> V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSU=ED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> _ 5 LETTER OF CF=DIT 6 EXEMPTION L 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 ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING I.❑ it.IV III O <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; AaPLICANT'S TITLE DATE MONTHIDAY/YEAR <br /> _7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION A FACILITY# <br /> 1 <br /> o C�- <br /> _OCATIONCO TIONAL CENSUS =-._T' OIT�C -�'i4 SGPVIS'S DySTRICT 0DE - P 0NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,ONLESS THIS IS A CHANGE OF SITE INFORMATI N ONLY. <br /> .. A i"a": FILE THIS FORM WITH THE LOCAL AGENCY 11.1PLENIENTING THE UNDERGROUND STORAGE TANK REGULATIONS` j i <br /> FOR0033A-R6 <br /> 0 0 e <br />