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STATE OF CALIFORNIA0 <br />STATE WATER RESOURCES CONTROL BOARD 3 3 <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :��' mii to <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY <br />❑ 1 NEW PERMIT <br />❑ 3 RENEWAL PERMIT <br />❑ 5 CHANGE OF INFORMATION <br />❑ 7 PERMANENTLY CLOSED SlIr <br />ONE ITEM <br />f❑ 2 INTERIM PERMIT <br />❑ 4 AMENDED PERMIT <br />❑ 6 TEMPORARY SITE CLOSURE <br />CITY NAME <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Gr vl C C <br />I. t'ALAu I Y/JI t t INt'UhMA I IUN & AUUhtbJ - (MUJ I Ct t UMMLt 1 tU) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />NIGHTS: AME (LAST, FIRST) PHONE # WITH AREA CODE <br />- <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />1;2-tORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Gr vl C C <br />CA3 <br />36 <br />�K <br />TOINDIC TE D ORPORATION Q INDIVIDUAL IQ PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS E;1- I GAS STATION 2 DISTRIBUTORQ <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />IQ 3 FARM a 4 PROCESSOR a 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />q <br />DAYS: NAME (LAST. FIRST) <br />NIGHTS: AME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME nn <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />G\ <br />1;2-tORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STAT ZIP CODE <br />PONE # WITH AREA CODE <br />-Z <br />CITY NAME <br />� S <br />20 O -oma► <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />���� <br />�U V, <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />011 <br />IQ CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE ZIP CODE <br />HONE #WITH AREA CODE <br />�K <br />�s 336 <br />z©5 Z3225 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ [4-147 -1 e912_1 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED It, j <br />✓ box Io indicate Q 1 SELF-INSURED Q 2 GUARANTEE [?!j_3INSURANCE Q 4 SURETY BOND <br />Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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 checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. ❑ 11. ❑ 111. ❑ <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 MONTHIDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # F&AI X % 1 <br />Z <br />LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL C� 7 <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) FOROT13A-5 <br />