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boon e <br />STATE OF CALIFORNIA ,! <br />s <br />STATE WATER RESOURCES CONTROL BOARD s <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� ee <br />COMPLETE THIS FORM FOR EAC ACILrrvstTE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CL D SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br />I CACTI ITVICITF INFORMATION R ADDRFSS. fMIIST RE COMPLETEDI <br />DBA OR FAPILITY NAME <br />NAME OF OPERATOR <br />ADORE SS <br />CROSS STREET <br />PARCELA(OPTIOW <br />1 aftzNEAREST <br />f <br />✓ EoamlMkale 0 INDIVIDUAL <br /><n <br />b <br />CITY NAME ^ <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />CITY NAME <br />CA <br />/a. <br />Of) 7 <br />I/ BOX <br />TOINDICATE O CORPORATION Q INDMDUAL [_1 PARTNERSHIP O LOCAL -AGENCY 0 COUNTY -AGENCY 0 STATE -AGENCY 0 FEDEMLAGENCY <br />DISTRICTS <br />TYPE OF BUSINESS ❑ a GAS STATION 2 DISTRIBUTOR/ <br />IF INDIAN ❑ <br /># OF TANKS AT SITE <br />E. P. A. L D. # (op#bnal) <br />FARM 4 PROCESSOR OTHER <br />RESERVATION <br />3 <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />DAYS: ME (LA T. FIRST) <br />PHONE # WITH AREA CODE <br />X09} -?Br <br />DAYS: NAME (LAST. FIRST) <br />I PHONE # NTH AREA Go'. <br />NIGHTS: NAME (LAST. FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME — In <br />a&Z -\\Jry � <br />CARE OF ADDRESS INFORMATION <br />bw blMkale (] INDIVIDUAL O LOCAL -AGENCY 0 STATE -AGENCY <br />CORPORATION 0 PARTNERSHIP (] COUNTY -AGENCY E:1 FEDERALAGENCY <br />MAlll OR STREET ADDRESS <br />✓ EoamlMkale 0 INDIVIDUAL <br />O LOCAL -AGENCY 0 STATE -AGENCY <br />O CORPORATION 0 PARTNERSHIPO <br />COUNTY -AGENCY FEDERAL-AGENCY <br />CITY NAME <br />ST <br />QIR <br />ZIP DE' r <br />PHONE # WITH AREA CODE44 <br />16 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) 7T <br />NAME OF OWNER <br />W� <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />bw blMkale (] INDIVIDUAL O LOCAL -AGENCY 0 STATE -AGENCY <br />CORPORATION 0 PARTNERSHIP (] COUNTY -AGENCY E:1 FEDERALAGENCY <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 4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BECOMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ baa blMkab D I SELF-INSURED E-1 2 G ANTEE Q a INSURANCE Q 4 SURETY BOND <br />11 5 LETTEROFCREDT [ %EMPTION = N 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. ❑ it. ❑ III. ❑ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT <br />APPLICANTS NAME(PRINTED& SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEA <br />LOCAL AGENCY USE ONLY o 11L In fi -3 7 <br />I CO# JURISDICTNJN# FACILITY# <br />S <br />THIS FORM MUST BE ACCOMPANIED BY. AT LEAST (1) OR MORE PERMIT APPLICATION <br />FORM A (5.91) <br />V <br />C� <br />• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FOi100]]A3 \ <br />/y / 7 <br />