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✓ \.I esouw <br /> STATE OF CADFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT 3 RENEWAL PERMIT [::] 6 CHANGE OF INFORMATION T PERMANENTLY CL <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ME OF OPERATOR <br /> ADDRESS s- 45 / -Z- Ave. NEAREST CROSSES ET PARCELA(OPrpNAC <br /> CITU NAME`/—'/`,'' T��Y '�/�^' STATE ZIP CODE ITE P NE a W ITH AREA E <br /> �� CaODX <br /> g '2 v w333-tea <br /> TO INDICATE O CORPORATION (]INDIVIDUAL 0 PARTN"mP ID LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TAFJ(S AT SITE E.P.A. I.D.A'(oplimaq <br /> RESEflVATION / <br /> 3 FARM Q 4 PppCESSOR 0 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•Optional <br /> DAY9: NAME(LAIrr.rimn PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ZE vL b 4 Y 71213- T's6 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA C,011E - <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MML)N,C,911 STREET ADDRESS ✓ba tmM 0 INDIVIDUAL 0 LOCALAGENCY O STATEAGENCY <br /> / =CORPORATION 0 PARTNERSHIP 0 CWNryAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER � �„ CARE OF ADDRESS INFORMATION <br /> O .4 r c-rAL_ <br /> MALI OR STREET AADDDRESS• 2 ✓ box aWicW OINDIVIDUAL 0LOCALAGENCY 0STATEAGENCYO. /36� J 7 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCV <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> coi f r 04- <br /> IV. BOARD OP EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 1 41-F-1—FT–= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa NiMicNe 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETYBOND <br /> O 5 LETTEROFCREDIT 0 6 EXEMPTION 0 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 ch ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> L� a <br /> LOCATION CODE OPTIONA� CENS�T�ACT:1 -OPTIONAL SUPVIAS�nDiSTRICT CODE -OPTIONAL f 3 - 97 <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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> — � FORoa33A ae <br />