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osso°" � <br /> e <br /> STATE OF CALIFORNIA <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD s�,� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A � 1 <br /> G a" <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SRF <br /> ONE REM 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE S'0 <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAORF Cl;NAMECel, HjCA <br /> MEOFOPERATOR <br /> Q� N v AREST CROSS STREET PARCEL#(OFrIONAL) <br /> ADDRESS ^^--��-- <br /> arCITY NAME A ZIP CODE SITE PHONE WITH AREA CODE <br /> S-fak6,j <br /> TOIN BOX CORPORATION �INDIVIDUAL 0 PARTNERSHIP Ej LOCAL-AGENCY <br /> OCAL-DISTRIG CY COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> TS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM = 4 PROCESSOR [W 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optl <br /> DAYS: NAME ALAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> I N Sly s -szz— <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED -{ v <br /> NAME RE OF 53 INFORMATION <br /> p v a <br /> MAILING OR STREET ADDRESS '� beabinEbate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> A700 <br /> i Q �CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY I� FEDERAL-AGENCY <br /> CITU NAME STATE 21P CODE PHONE#WITH AREA CODE <br /> o c � 9535(0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> QS <br /> MAILING OR STREETADDRESS ✓ Mx0MIc" Q INDIVIDUAL O LOCALAGENCY 0 STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE S 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 - s. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMbat# O 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 A SUREtt BOND <br /> O 5 LETTEROFCREDIT 0 6 EXEMPTION O 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.[�] 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 A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> L AIDL3 i <br /> 44 e <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVIGOR-DISTRICT CODE -OPTIONAL �'�� <br /> 3,80 3 zr <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. ct <br /> FARM A(5-91\C\ - FOR0033A-5 <br /> �O <br />