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%W11/ 1 aou. r <br /> STATE OF CALIFORNIA ^t <br /> STATE WATER RESOURCES CONTROL BOARD p <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> h! I� COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> I-1 <br /> MARK ONLY 1 NEW PERMIT1.lI 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSEDESE11 <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACTyITY NAME NAME OF OPERATOR <br /> SvA� WEST— GTG�vo <br /> ADDRESS NEAREST CROSS STREET PMCEL#(OPTgNAL) <br /> 2 027- <br /> CITY NAME - STATE ZIP CODE ITE PHO E#WITH AREA CODE <br /> GOA CAI/ BOX <br /> TO INDICATE I-1 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL AGENCY D COUNTY-AGENCY STATE-AGENCY 0 FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS FV 1 GAS STATION 0 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#/optimal) <br /> RESERVATION <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)AMq �� 368-y Z <br /> PHONE a WITH AREA COOF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PWnNP If WITH AREA <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATION <br /> D li <br /> G STREET ADDRESS ✓ box bi^diraY [71 INDIVIDUAL D LOCAL-AGENCY 71 STATE AGENCY <br /> o J— u."' E=1 CORPORATION = PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY ir <br /> CITY NAME STATE ZIP CODE PONE# ITH AR,g�pE <br /> 3;5 /0-&6 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF QWp'.ER_ 1 D ��� CARE OF ADDRESS INFORMATION <br /> R STREET ADDRESS ✓ bor biMkale INDIVIDUAL E=j LOCAL-AGENCY (] STATE AGENCY <br /> R7/ J!5,- ��/wY �!� E=1 CORPORATION D PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEHONE#1(JITH_MREA�ADE <br /> 2elb �1133 JJll �0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4_1!�-F] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlkaie 0 1 SELF-INSURED F.]2 GUARANTEE 3 INSURANCE 0 4 SUR� <br /> D 5 LETTER OF CREDIT =1 6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank 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. IL Ll III, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1 TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# - <br /> 3 1 1 _1 1 1 1 - sp33 S <br /> LOCATION CODE -OPTIONAL OZ CENSUS TR;gT ;OPTIONAL OR-DISTRICT CODE -OPTIONAL 9 3- � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION Y. <br /> FORM A(12 91) FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> j \` v �(Y <br />