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STATE OF CALIFORNIA r `i <br /> STATE WATER RESOURCES CONTROL BOARD g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH LITYISITE <br /> MARK ONLY F7 1 NEW PERMIT I7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY C 0 SRE <br /> ONE ITEM ❑ 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS,,,� vi NEAREST CROSS STREET PARCEL#(OPTIONAu <br /> Cltt NAME J STATE ZIP CODE TE PH NE#WITH AREA COIJE <br /> v# - <br /> CA 32 3- 6666 <br /> BOX <br /> TOINOCATE O CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN N OF TANKS AT SITE E.P.A. I.D.a(op!wnap <br /> E713 FARM O 4 PROCESSOR 5 RESERVATION <br /> OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:14AME(LAS'' Sn Al� PHONEa WI�H�EA COOki/ DAYS: NAME(LAST,FIRST) <br /> PHONE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE/7!5/( NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> vca A,e GTA L <br /> MAILING OR�$JTREET ADDRESS ✓ boa 0kml a LA INDIVIDUAL LOCAL-AGENCY D BTATEAGENCY <br /> f • p, /J�J� �jl,� =CORPORATION 0 PARTNERSHIP OWNTYAGENCY FEDERAL-AGENCY <br /> CITU NAME STATE^ ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> O <br /> MAI INGORSTREEg;EA2WF1jESESS //) ✓ bOxbinGNale INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> •0- 215el / =CORPORATION PARTNERSHIP L:j CWMY#GENCY FEDERAL-AGENCY <br /> CITU NAN,Ea STATER ZIP�ODE�r PHONE WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBEDERR/--Call- <br /> -all(916))3/2x3-995555 if questions arise. <br /> TY(TK) HO 4 4 -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa 0md,,a,. 1 SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTER OF CREDIT Q 6 EXEMPTION (�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: L 0 II.E 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY* <br /> m 03 GAG Yf <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT LODE -OPTIONAL F�.2 /,A <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) � FOi19033A5 <br />