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STATE OF CALIFORNIA ` `y <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / �DERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FA (SITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PER TLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME — NAME OF OPERATOR <br /> ate. s /icG <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STAZIP C <br /> TE ODE SITE PHONE#WITH AREA CODE <br /> CA <br /> TOIN BOX Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q DISTRICTS <br /> CAL-AGENCY Q COUNTY AGENCY Q STATE-AGENCY Q FEDERALAGENCY <br /> TYPEOF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR RE,/ IF INDIAN <br /> SERVATION #OF TANKS AT SITE E.P.A. 1.0.s(aprionaq <br /> Q 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY C NTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE I WITH AREA nQnF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> H AREA CODE <br /> If. PROPERTY OWNER IN RMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bYib WKiN Q INDIVIDUAL O LOCAL-AGENCY Q STATE-AMCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFOR ATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Doe 0ir&mla Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q CAUNrY#GENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EquortATION UST STORAGE F:tf,,ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HO - p <br /> V. PETROLEUM US ITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ ew n'vlfnau Q T SELFINSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTEROFCREDrT Q 5 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b or II is checked. <br /> CHECK ONE SOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR NTED B SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# �� �F�ACILITY# <br /> � <br /> <SLL'L-L-I--LSL-LJ1J <br /> LOCATION CODE -OPTIONAL ICENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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. <br /> FORM A(5-91) _ \,CFOR0033A-5 <br /> r�, �n('1 i�•✓i .a/•+rc-t]-r-'"`7_' CJ's <br />