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'�soun e.q c <br /> STATE OF CALIFORNIA ° <br /> A <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �e <br /> G . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F__] t NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE E <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEA ST CROSS STREET PARCEL#(OPTIONAL) <br /> _ /O ��- 40 <br /> CITY NAME STATE ZI COD E � ITE PHONE#WITH AREA CODE <br /> CA 37 <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> CA <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTORI/ IF INDIAN #OF TANK AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS AME(LAST,FIRST) PHONE#WITH AREA DAYS: NAME(LAST,FIRST) <br /> _ _( S —7 <br /> NIGHTS: INJAME(LASf.rIRST) PHONE#WITH AREA GCIIDE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRES INFOR ATION <br /> � / ez�l <br /> MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> PORATION PARTNERSHIP COUNTY-AGENCY E:] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COD PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAMESTATES ZIP CODEPHONE#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 41-L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 712 GUARANTEE E-] 3 INSURANCE 0 4 SURETY BOND <br /> C� 5 LETTER OF CREDIT L=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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ 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 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> I L_, ? w <br /> LOCATION CODE OPTIONAL ICE NSU TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z� 4e. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONL . <br /> FORM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION <br /> . FO 0033A-R6 <br /> # <br /> 1 <br />