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�/ '.� •eboua e <br /> STATE OF CALIFORNIA °. <br /> �- STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> C�(,eONN,N <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE - <br /> MARK ONLY 0 1 NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILTYN E ^rP�).(/ M OF OPERATOR <br /> ADDRESS d da / NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP / SITE PHONE WITH AREA DE <br /> _ CAv BOX <br /> TO INDCATE O CORPORATION D INDIVIDUAL. E-1 ARTNERSHIP O LOCAL-AGENCY 0 COUWYAGENCY O STATE-AGENCY 0 FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR D RESERVATION <br /> INDIAN N OF TANKS AT SITE E.P.A. I.D.0 Whonal) <br /> 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(AST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE•WITH AREA CODE NIGHTS: NAME <br /> PHONE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED �s <br /> NAME -1 /VJMXOF ADDRESS INFORMATION w ' c <br /> /� IX A 4 %FEDERAL-AGENCY_ <br /> MAILING ORS ET ADDRESS •bmMCHe INDIVIDUAL D LOCAL-AGEN <br /> PJ V COR COUNTY AGE <br /> CITU NAME I — T STATEI ZIP CODE�� PHONE N WITH A_ <br /> Cn/Vw ....5 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• JC4,z asa••'i1-- Em biMkm D INDIVIDUAL - O LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION l= PARTNERSHIP ElCOIINTYAGENCY D FEDEMLAGENCY <br /> CITY NAMESTATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L444 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Lo•mintlkate I� 1 SELF-INSURED O 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT O 6 EXEMPTION W OTHER <br /> 71 <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.O 11,x <br /> III.O <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 B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N .../M, , � I, +3 � JURISDI <br /> CTION p FACILITY <br /> 1 <br /> Ur1/4 �V Ir <br /> -47 <br /> LOGATIONCODE OPTIONAL (CENSUS TRACTx .Op IOA(4L SUPVISOR-DIST CT CODE -OPTIONAL � <br /> THIS FO MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> kORM A(12 90 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UND ROUND STORAGE TANK REGULATIONS <br /> • FIX10033AR6 <br />