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91 0 <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD r <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />�.. o <br />COMPLETE THIS FORM FOR EACH F ITY/SITE <br />MARK ONLY 7, t NEW PERMIT E:] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT L0Ejj SITE <br />F-1ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE a WITH AREA GODF <br />NAME OF OPERATOR <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE I WITH AREA CODE <br />ZIP CODE <br />e <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL# (OPTIONAL) <br />lie <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />h <br />CA <br />9 5, <br />91-y6 yii <br />✓ BOX <br />TO INDICATE <br />CORPORATION <br />0 INDIVIDUAL 0 PARTNERSHIP <br />LOCAL -AGENCY 0 COUNTY -AGENCY <br />STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS <br />1 GAS STATION <br />2 DISTRIBUTOR <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM <br />O 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />3 <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 a WITH AREA GODF <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE I WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />a CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST RE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS • <br />✓ box IDindicate INDIVIDUAL OLOCAL-AGENCY (] STATE -AGENCY <br />CORPORATION PARTNERSHIP COUNTY -AGENCY 0 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 1[4-T-4]-[1 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) – IDENTIFY THE METHOD(S) USED <br />✓ box to indicate E7 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br />O 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 Lis checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. F7 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 />6v AT'0R 2s' <br />LOCATION CODE OPTIONAL I CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />Z ya -3 <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFO LY. <br />FORM A (12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />0 <br />- 0 <br />: FOR0033A-R6 <br />