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-_ ' esouA es <br /> STATE OF CALIFORNIA <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARDAL <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA 4� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT 0 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 /> 06 0 . 1 <br /> ADDRESS NEAREST CROSS STREET PARCEL# PTIONAL) <br /> i <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> rG CA D°(- — <br /> ✓ 8 <br /> TO INDICATE CORPORATION E(d'INDIVIDUAL = PARTNERSHIP [] LOCAL-AGENCY E] COUNTY-AGENCY [] STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS E� 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> (�"_ U — '71 PHONE:*WITH AREA rO F <br /> NIGHTS: NAME(LAST,FI S PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODEII. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 11144 1` CARE OF ADDRESS INFORMATION <br /> J <br /> MAILIN A STREET ADDRESS ✓ tax to indicate INDIVIDUAL [] LOCAL-AGENCY [] STATE-AGENCY <br /> []CORPORATION = PARTNERSHIP [] COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �L 1 �_ (yl—2154 -CALL <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME F OWNER CARE OF ADDRESS INFORMATION <br /> MAILI ORSTREET ADDRESS ✓ box to indicate NDIVIDUAL [] LOCAL-AGENCY [] STATE-AGENCY <br /> []CORPORATION = PARTNERSHIP [] COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> - — <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box tnindicate 0 1 SELF-INSURED [] 2 GUARANTEE 3 INSURANCE []4 SURETY BOND <br /> 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 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.[�or 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 /> f- L L4 —� <br /> LOCAL AGENCY USE 0 LY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTI <br /> LOCATION CODE -OPTIONAL CENSUS 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 /> FO RM A(5-91) FOR0033A-5 <br />