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STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD ; <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA !� " <br />• C�(iFOR N,� <br />CQWLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY t NEW PERMIT ENEWAL PERMIT E] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br />ONE ITEM n 2 INTERIM PERMIT ,'AMENDED PERMIT [LI 6 TEMPORARY SITE CLOSURE v/ <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR CILITY NAME z1rO <br />!✓� <br />A6 e <br />NAM ERATQ$., <br />AD ESS <br />NEAREST CROSS STET <br />PARCEL # (OPTIONAL) <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />i <br />CITY <br />STATE <br />ZIP C E <br />SITE P ONE # WITH AREA CODE <br />_- <br />CA <br />COUNTY -AGENCY <br />— (oZ—� <br />TO DB) ATE O C70INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY 0 COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS I GAS STATION 0 2 DISTRIBUTORRESERVADI <br />AN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />.310 ,y <br />- o <br />3 FARM 4 PROCESSOR 5 OTHER <br />0 F] 0 <br />OR T RUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - ontional <br />DAYS: NAME (LAST. FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODIP <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II- PRnPFRTY nWNFR INFORMATION - (MI IST RF COMPI FTFn) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />CARE OF ADDRESS INFORMATION <br />MAILI OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL � LOCAL -AGENCY (� STATE -AGENCY <br />MAI IN R S REET A RESS <br />l/1 <br />✓ box to indicate INDIVIDUAL <br />LOCAL -AGENCY <br />STATE -AGENCY <br />t r -56)3g <br />0 CORPORATION PARTNERSHIP <br />COUNTY -AGENCY <br />0 FEDERAL -AGENCY <br />CITY MME ` <br />STN <br />T <br />ZI CODE <br />PHONE # WITH AREA CODE <br />.310 ,y <br />- o <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF -OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILI OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL � LOCAL -AGENCY (� STATE -AGENCY <br />CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NA <br />STAj <br />Z OD HONE # WITH AREA CODE <br />02 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 141.4)- C�® <br />V. PETROLEUM UST FINANCId RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate f I SELF.INSURED 0 2 GUARANTEE 0 3 INSURANCE L 4 SUR BOND <br />LJ 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 qrAm Wed. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <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) APPLICANT'S TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />LOCATION COyDE, OPTIONAL 'CENSUS TRACT # -_OPTIONAL _ _ SUPVISOR - DISjRIOT CODE -OPTIONAL <br />I U I -4-&P <br />• W L/ 7 !k -j ITi' - <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 (1z-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />0 <br />0 <br />FOR0033A-R6 <br />