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STATE OF CALIFORNIA M1 ° <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w� <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F_-] t NEW PERMIT 3 RENEWAL PERMIT [�] 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM u 2 INTERIM PERMIT F__1 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADD S � J NEAR�C�OSSS� ARE^T� PARCELm(OPTIONAL) <br /> CITY NA E STATE ZIP COD SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ <br /> BOX <br /> TO INDICATE CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION = 2 DISTRIBUTOR0 R SER INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ON <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS, NAM LAST FIRST) PHONE#WITH AREA CODE DAYCS: NAME(LAST,FIRST) <br /> _ j r —JPHONE&WITH AREA mnp <br /> NIGHTS: AM (LAST IRST) 91 <br /> PHONE# TH AREA C DE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA COn;: <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box bindicate INDIVIDUAL <br /> LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME [STATE ZIP CODE 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 [41 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION L] 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. 11.F] 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# FAG4LITY# <br /> LOCATION CODE -OPTIONAL ICE NSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT 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 /> FOAM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> A- <br /> is Q e�,, /— ?,3 <br />