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• �50URGE5 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o <br /> C�IIfOP N�f <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F__] 7 PERMANENTLY CLOSED <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRA ACJ II J yAME D :h, I Z j1 NAME OF OPERATOR <br /> AD \ A, / NEAREST CROSS STREEi PARCEL#(OPTIONAL) <br /> CITY M (�f/�r STAT !ZIP SIIOH�E#WITH AREA COD <br /> CA ,�bux <br /> TO INDICATE CORPORATION INDIVIDUAL (] PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a 1 GAS STATION = 2 DISTRIBUTORRESER INDIAN <br /> #OF T;7 AT SITE E.P.A. I.D.A(optional) <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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM ^ ' CARE OF ADDRESS INFORMATION <br /> MAI 0 STRE ADDR SS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> I � CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY STZIP COD O PHO #,WfITH AR C /) <br /> mm& . 5 5 <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 <br /> 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE 7CODE 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 - 101 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE ETHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> L� 5 LETTER OF CREDIT 6 EXEMPTION 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.Y 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# <br /> Mi L I I I V-16o <br /> LOCATI N ODE OPTIONAL VNSYUSTRV -OP Ajlt� SUPVISOR- IST ICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR l/MOORE PERMIT APPLICATION- FOfTM B,UNLESS THIS IS A CHANGE OF SITE INFORMATTUN ONLY. <br /> FORM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> • FOR0033A-R6 <br />