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STATE OFCAUFORMA .e <br /> STATE WATER RESOURCES CONTROL BOARD = <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FOgM FOO EACH FACILRYISRE °""°""'� ° <br /> MARK ONLY ❑ 1 NEW PERMIT3 RENEWAL PERMIT <br /> E:]ONE ITEM ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> 1 �-lJ NAME OF OPERATOR -L7 <br /> ADDRESS <br /> NEAFJES7 CROSS STREET PARCELFIOPTIONAU <br /> CITY NAME C.N L, APP13a-696 -G 3 <br /> C GN STATE LP CODE SFE PHONE r WITH AREA CODE <br /> �J <br /> lax CA %S <br /> ✓ <br /> TO INDICATE �CORPORATON p INDIVIDUAL p PARTNERSHIP p LOCAL-AGENCY p COUNTY AGENCY p STATE-AGENCY p FEOEMLrAaNCY <br /> DISTRICTS <br /> TYPE OF BUSINESS c]'t 1 GAS STATION C 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. 1.D.a(gaGorMe <br /> p 3 FARM p * PROCESSOR5 O RESERVATION <br /> OTHER A <br /> D ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•OPtI611tl <br /> DAYS:ppME ILASi^FIRST) PIgNE ar WITH AREA CODE CIA ME(LAST,FIRS) <br /> A <br /> (� <br /> \\11 /C / OA. 1�CA ' <br /> NIGHTS: NAM (LAST,FIRS HONE*WITHAR ACOD <br /> PE NIGH S: NAME(LAST,FIRS) fin` <br /> u2G -3S 5,6 /p G� 1/ <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME - CARE OF ADDRESS INFORMATION <br /> Z,17 JIC 14 Al <br /> MAILING Ofi STREETADDRESS _ ✓ OmbN ex* p INDIVIDUAL p LOCAL-AGENCY p STATE-AGENCY <br /> O O/1/ / �PORATKNN p PARTNERSHIP p COUNTY-AGENCY p FEDMAGENCY <br /> CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE <br /> 1A )zzL �4 G - G <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /C � G 1 e <br /> MAILING OR STREET ADDRESS Dot bvbbM* p INDIVIDUAL p LOCAL-AGENCY p STATE AGENCY <br /> /— Il-( p CORPORATION p PARTNERSHIP p COUNTY AGENCY p FEDEPALAGENCY <br /> CITY NAME $^TATE„ ZIP CODE PH^ONE A WITH AREA CODE <br /> ( Y Z <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 it questions arise. <br /> TY(TK) HO F4]-4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)–IDENTIFY THE METHODS) USED <br /> ✓ Do�bIMk�M L&INSURED p 2 GUARANTEE p 3 MSURANCE A SJRETY 9]NO <br /> p 5 LETTEROFCAEDIT p 6 EXEMPTION p 99 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. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) P ANTSTITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N FACILITY x 3 <br /> m � 3 10 a <br /> LOCATION CODE -OPTIONAL iCENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Y <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF E INFORMATION ONLY. <br /> FORM A(591) FOR0003A-5 <br /> ALIC' ,HF, <br /> .A/ <br />