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• • �50UR es <br /> STATE OF CALIFORNIA t o° <br /> STATE WATER RESOURCES CONTROL BOARD a_ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> 4 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY <br /> 1 NEW PER 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> t--� _ <br /> ONE ITEM L_ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE =n 5 C' � <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS / NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3.2 <br /> CITY NAME STATEJ ZIP CODE(j SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX `/ <br /> TO INDICATE Icy'CORPORATION j� INDIVIDUAL �� PARTNERSHIP [.___ LOCAL-AGENCY �] COUNTY-AGENCY [] STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS !�(I 1 GAS STATION F_ i 2 DISTRIBUTOR IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> /� RES✓ERVATION <br /> _ 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS o o a 413 3 3 8 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> _��r-v.�lo -1Y►i1Cg__ C /�. _ Ssab �vs� — PHONE#WITH ARFArX= <br /> - <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 0 0 9,9,0— O "I'V19 PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD SS J ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> XCORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME /> ` STATE ZIP CODE PHONE#WITH AREA CODE <br /> rzt -t- C 9ys3 9- SO <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 STATE-AGENCY <br /> CORPORATION [J PARTNERSHIP COUNTY-AGENCY 0 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 1, 4 14 -L o f a :?L 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT _.i 6 EXEMPTION 99 OTHER �--� t:1 1A <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILI-ING: 1.F] II. III. <br /> THIS FORM,{lAS BEEN COMPLETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APP_ICANTS TITLE DATE MONTH/DAY/YEAR <br /> A <br /> L CAL AGENCY USE LY <br /> COUNTY# JURISDICTION# FACILITY# $-{() <br /> I <br /> _lam <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR DISTRICT CODE -OPTIONAL <br /> � 6-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 /> FORM A(12 911 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br />