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• �uuacFs <br />STATE OF CALIFORNIA ^�� �',� <br />STATE WATER RESOURCES CONTROL BOARD 3 _�. '� <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />��. iE a <br />rs �Y •* . -�� o <br />I- <br />C-(I-VNN� <br />COYPLETE THIS FORM FOR EACHJ4CILfTYISITE <br />MARK ONLY 1 NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMATION [�] 7 PERMANENTLY CLOSED SITE /'� / <br />ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ��6 TEMPORARY SITE CLOSURE 4w—% C. <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR CILITY NAME � <br />NAM��ERATQ$., <br />AD ESS <br />-61 <br />NE AREST CROSS STJJEET PARCEL #(OPix)NAL) <br />TY <br />STATE ZIP CQpE <br />CA <br />SITE PHONEll#WITH AREA CODE <br />✓box <br />TO INDICATE iiCOR ATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br />Q ✓ IF INDIAN <br /># OF TA AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM Q 4 PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY QFEDERAL-AGENCY <br />CITY ME <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PFRRnN t-,rm lneavl - ,,.,ti_.t <br />DAYS: NAME (LAST. FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST] PHnNF rWITH ARFACODF <br />COUNTY # <br />WITH AREA 00- <br />11. PROPERTY OWNER INFORMATION - (Ml1ST RF COMPI FTFm <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILI OR STREET ADDRESS • <br />CARE OF ADDRESS INFORMATION <br />COUNTY # <br />✓ box to indicate Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY <br />CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NA <br />MAILING QRS R' ETA DRESS <br />^ L9 <br />✓ box Q INDIVIDUAL Q LOCAL -AGENCY Q STATE AGENCY <br />LL/ �J[ <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY QFEDERAL-AGENCY <br />CITY ME <br />FO ra A 1 e,; FILE THIS <br />FORM WITH TH I CAL AGENCY IMPLEMENTING THE <br />ST�g _ <br />ZIP CODE PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST RE COMPI FTFm <br />NAME OF NER <br />CARE OF ADDRESS INFORMATION <br />MAILI OR STREET ADDRESS • <br />a <br />.) <br />COUNTY # <br />✓ box to indicate Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY <br />CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NA <br />LOCATICN CODE OPTIONAL <br />STAP ZI ODE HONE #WITH AREA CODE <br />IV. BUAHO OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HO j 4 I4 J -LL0 <br />V. PETROLEUM UST FINANCI,9 RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box oindicate I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br />X 5 LETTER OF CREDIT Q 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 ecked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L 1=! if. vIII. L J! <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,DAY;YEAR <br />LOCAL AGENCY USE ONLY <br />4j2U___- <br />COUNTY # <br />JURISDICTION # <br />a1A <br />FACILITY # <br />LOCATICN CODE OPTIONAL <br />'CENSUS TRACT # --OPTIONAL SUPVISOR - DISZRI T CODE -OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION <br />• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORLY. <br />FO ra A 1 e,; FILE THIS <br />FORM WITH TH I CAL AGENCY IMPLEMENTING THE <br />UNDERGROUND STORA E TANK REGULATIONS' <br />arN�r;i3A-"n6 <br />