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0 0 <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />MARK ONLY 0 I NEW PERMIT r-1 7 RENEWAL PERMIT [:!r5 CHANGE OF INFORMATION [::] 7 PE ANENTLY CLOSED SITE <br />ONE RO EM F7 2 INTERIM PERMIT 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE '% /y <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) I <br />DBA OR FACILITY NAME - <br />NAME OF OPERATOR <br />NIGHTS: NAME (LAST, FIRST) PHONE 8 WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />ADDRES3 <br />NEAREST CROSS STREET <br />PARCEU( AL <br />PHONE 0 WITH AREA I- <br />CITY NAME <br />STATEZIP <br />CODE <br />SITE PHONE N WITH AREA CODE <br />Q o„ <br />CA <br />BOX <br />TO INDICATE O CORPORATION Q INDIVIDUAL O PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY D STATE -AGENCY Q FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS O 7 GAS STATION O 2 DISTR18UTORO <br />✓ IFRVINDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM O 4 PROCESSOR 0 5 OTHER <br />RESEATION <br />I OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PFRS2nM 1SFOnun&0V1 _,....o.....i <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (LAST, FIRST) PHONE 8 WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />II. PROPERTY OWNFR INFORMATInN. IMIICT RF Pn&ADI FTRm <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ boa bkAlato INDIVOUAL O LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION 0 PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE 0 WITH AREA I- <br />111. TANK OWNER INFORMATION - IMIIST RF f.nMP1 cTr:rn <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ boa biMkata 0 INDIVIDUAL 0 LOCAL -AGENCY Q STATE -AGENCY <br />0 CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY O FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />1#. cvMnu yr CUUALILAI Ivry UZI 1 sI UHAUt rtt ACI:UUN I NUMBER - Call (916) 323.9555 if questions arise. <br />TY (TK) HO 4 4 Lot,? Li -7/ y <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BECOMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ boa o Mule I SELF-INSURED 0 2 GUARANTEE O 7 INSURANCE 4 SURETY 9oNO <br />O 5 LETTER OF CREDIT = 5 EXEMPTION EEI'% OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b or 11 is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II. Ej III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANTS NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br />LVVMLMLCINVr VOCVINLT <br />LCOUNTY # JURISDICTION # FACILITY # <br />F3 -T-71 I I / L <br />THIS -FORM MUST BE ACCOMPANIED BY AT LEAST (T) OR MORE PERMIT APPLICATION <br />-DISTRICT <br />UNLESS THIS IS A CHANGF OF SRF IMFnRMATInN nNI V <br />j / FOR0037A.5 <br />