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ebouA e <br />STATE OF CALIFORNIA M1e P oOt <br />STATE WATER RESOURCES CONTROL BOARD , <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A : 'tee <br />/OMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY F__] 1 NEW PERMIT IV3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E 7 PERMANENTLY CLOSED,SI,y, <br />ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OP,4iACILITY NAME���� <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />NAME OF OPERATOR <br />ADD ESS <br />V <br />NEAREST OSS�EET <br />PARCEL#(OPTIONAL) <br />CITY NAME <br />STY <br />C E <br />STACtA <br />ZIP CO E Z03 <br />SITE PHONE #WITH AREA CODE <br />✓ BOX <br />TO INDICATE <br />CORPORATION Q INDIVIDUAL Q PARTNERSHIP <br />Q LOCAL -AGENCY Q COUNTY -AGENCY Q STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS = <br />1 GAS STATION 0 2 DISTRIBUTORRESEIF <br />INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />R ON <br />Q <br />3 FARM Q 4 PROCESSOR Q 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />IL -L" <br />j 1 <br />r <br />CARE OF ADDRESS INFORMATION <br />MAI OR STREET <br />DRESS <br />✓ box bindicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />V <br />�x <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY N E <br />STY <br />C E <br />ZI ODE PHONE # WITH AREA CODE <br />� OZ- 69gl Zl 3- �d4- S30 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # 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 4- O 5 0 <br />V. PETROLEUM UST FINANCI RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ <br />box bindicate EV 1 SELF-INSURED =]2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br />Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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 i checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 0 11:-; _ 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/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />39 <br />LOCATION CO[y-pPTIONAL CENSUS TRACT#; QPTIO A SUPVISORDITRICT CODE -OPTIONAL <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 (5-91) FOR0033A-5 <br />