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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A Ya ,- <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANE ZI, <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 1 <br /> DBA OR FACILITY NAMENAME OF OPERATO <br /> ADDRESS NEA ST CROSS STREET PARCEL#(OPTIONAL) <br /> OAJ,. �G ,+iJ <br /> CITY NAME STATE ZIP CO �i SITE PHONE#WITH AREA COD <br /> ✓BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' = STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> It owner of UST is a public agency,complete the following name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR v1 IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> tl 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> 0 0 OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME LAST,FIRST) PHONE#WITH AREA CODE DAYq: NAME LAST,FPHONE#WITH AREA CODE <br /> �' s e o � FIRST) •--.-74 <br /> NIGHTS: LAST,FIRST) HONE#WITH AREA COD NIGHTS: NA (LAST,FIRST) PHONE#WITH AREA CODE <br /> Cy VV5SbeAofIca — AV 01_ / <br /> II. PROPERTY ANER INFORMATION.(MUST BE COMPLETED) <br /> NAME /-�. I ©� • �a CARE OF A DRESS INFORMA <br /> 6/J"" L all L• cJ <br /> MAILING OR STREODRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ® o '540" CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ST&E ZIP CODE PHONE#WITH AREA CODE <br /> 1;0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER i CARE OF ADDRESS INFORMATION <br /> L � <br /> MAILING ORSTREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> ®, (.+ CJ 0 CORPORATION (] PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP C E PHONE#WITH AREA CODE <br /> " ' - c0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4_T4- -loll ITOFA_5� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicateSELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND <br /> 1 <br /> N9 STATE FUND&CHIEF FINANCIAL OFFICER LETrER a 9 STATE FUND a CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 0 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.❑ 1 111.W <br /> 1. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWN A (P IGNA RE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LO L A USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL Tu_PVISOR•DISTRICT CODE -OPTIONAL I O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONO . <br /> FORMA(6-95) OWNER MUST FILE THIS FORM#THE LOCAL AGENCY IMPLEMENTING THE UNDERGROIOTORAGE TANK REGULATIONS <br />