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•�'yJ,gCr4 c <br /> STATE OF CALIFORNIA a' <br /> STATE`NATER RESOURCES CONTROL BOARD -- <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ya <br /> y, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENT SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS , NEAREST CROSS�EET PARCEL x(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CAI !2-5-37 <br /> TOINDICATEQ CORPORATION Q INDIVIDUAL Q ARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.0.#(optional) <br /> ❑ 0 RESERVATION <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 D NAME(LAST,FIRST)- _ <br /> e„W4Tr� 9)�-(- =2721 u z/h / _ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PH #WITH ARG A CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME/ CARE OF ADDRESS INFORMATION <br /> M LING ✓ box misdate Q INDIVIDUAL Q LOCAL•AGENCYQ STATE•AGENCY <br /> d etAD” Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CI r� STATE ZIP COO n PH E*WITH AREA CODE I / <br /> III. "TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> � CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL_ Q.-L=_L•AGENCY Q• Y <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME ��— STATE I ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOAFtO OF EQUALIZATION UST STORAG FEE ACCO NUMBER-Call(916)323-9555 if questions arise. <br /> TY(T HQ 4 4 - 0 <br /> V. PETR M UST FINANCIAL RES PONSIBILITY"(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate =2 GUARANTEE . 3 INS GE' Q 4 SURETY BOND <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPTION QTI <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless or II is check <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN R <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPUCANT'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> IM —10G 37 lolol ] I '?, <br /> LOCATION CODE -OPTIONAL CENSUS TRACT OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 2 #3 a <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 /> FORMA(5-91) � �R�- J <br /> FOR0033A-S <br />