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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD 3 , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> •Cil Boll N� <br /> COMPLETE THIS FORM FOR EACH FACT Y/SITE <br /> MARK ONLY S 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S <br /> ONE ITEM J 2 INTERIM PERMIT U 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FA LITY NAME 1 NAME OF OPERATOR <br /> \ <br /> ADDRESSII�� NEAR ST CROSS,sTREET PARCEL#(OPTIONAL) <br /> '3 <br /> 3 '30 AJ Att- C�eiCD tcee <br /> CITY NAME _ STA(T;EA ZIP CODE SITE PHONE#WITH AREA CODE <br /> S C '� <br /> --- ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR = ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION M <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS V/ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WI AREA CODE DAYS: NAME(LAST,FIRST) <br /> L_t . �� 9--77-Z5 <br /> PHONE 4 WITH AREA rf)f)r- <br /> NIGHTS: NAME(LAST,FIRSTS— PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> Ol CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME / STATE ZIP CODE PHONE#WITH AREA CODE <br /> c r c 01 42N <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 0 LOCAL-AGENCY STATE-AGENCY <br /> (�CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> I <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate h 1 SELF-INSURED []2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> L_1 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it. 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 At FACILITY# <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z3 2z o -S- y3 4� A <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLE S THIS IS A CHANGE OF SITE INFORMATION ONLY. !\ <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br /> 1-�c . ��a-5 • <br />