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STATE OF CALIFORNIA 4b <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY NEW PERMIT F7 3 RENEWAL PERMIT J 5 CHANGE OF INFORMATION n 7 <br />ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I. FACILITYLSITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />Y <br />D� <br />DBA OR FACILITY NAME/ /� ,� p , T ' �/� ZS <br />�N1 �1 /� 1 �L! (L/ t xG, <br />NAME OF OPERATOR <br />ADDRESS <br />CITY NAME <br />NEAREST CROSS STREET PARCEL # (OPTIONAL) <br />ZIP CD/QE� / SITE PHONE #WITH AREA CODE <br />STATCEA <br />✓ box bindicateUA <br />I [v- <br />= CORPORATION AR P <br />TOINDIICATE E6<66PORATION` INDIVIDU PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY Cj STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS t GAS STATION O 2 DISTRIBUTOR / <br />n ✓ IF INDIAN <br />L---J <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />RESERVATION <br />3 FARM a 4 PROCESSOR 5 OTHER <br />�✓J <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />II_ PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF AOORESS T <br />DATE MONTH/DAYNEAR <br />MAILING OR STREET ADDRESS <br />✓ box bindicateUA <br />ENCY STATE -AGENCY <br />= CORPORATION AR P <br />a COU AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE ZIP CODE <br />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 b indicate INDIVIDUAL LCCAL-AGENCY (� STATE -AGENCY <br />S/ (� CORPORATION Q PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NA ^ t �D /V U' 66e, STATE ZIP CODE PHONE * WITH AREA CODE <br />�V <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions A e. <br />TY (TK) HQ !4L44_1-1_1 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate t SELF-INSURED 2 GUARANTEE Cf 3 INSURANCE 4 SURETY BOND <br />5 LETTER OF CREDIT 6 EXEMPTION Cf 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. ❑ III. 71 <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) <br />APPLICANTS TITLE <br />DATE MONTH/DAYNEAR <br />— Z/ <br />LOCAL AGENCY USE ONLY G✓�� <br />COUNTY # JURISDICTION # FACILITY # <br />39 _ _Z_L� - 1001:150 <br />710 <br />LOCATI CODE OPNAL CENSUS_ TRACT # - OPTIONAL SUPVISOR DISTRICT CODE - P L <br />'z v G� <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST Ill OR MORE PERMIT APPLICATION • FORM B. U ESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORM A (1291) <br />FILE THIS FORM WITH THE LOCALAGENCY tdPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />r44- <br />FOR0033A-R6 <br />C <br />