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STATE OF CAUFORNIA `. <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ne <br /> o.N <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT C, 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Sb <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ` NAME OF OPERATOR <br /> G <br /> ADDRESS /+ NEAREST CROSS STREET PARCEL#(OPRONALI <br /> 17 /r � l �Lc -� (,J <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓ BOX <br /> TO INDICATE L-1 CORPORATION 0 INDIVIDUAL E7 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY I] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> A,,t/Z.h <br /> NIGHTS: NAME(LAU.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Z PHONE 4 WITH AREA CODE <br /> �x J <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ��/'7 <br /> MAILING ORSTREETADDRESS o ✓ box bbdb L_j INDIVIDUAL LOCAL-AGENCY (] STATEAGENCY <br /> Pc O Y PFJ X j 3 7-7 0 CORPORATION L-1 PARTNERSHIP COUNTYAGENCY L-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 0'qklu 912n ;7- <br /> Ill. <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S6! cc <br /> MAILING OR STREET ADDRESS ✓ bor blMbaie INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> I�CORPORATION E-1 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO F4[4] 0 3 a 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ b 1 I indkale 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> I�5 LETTER OF CREDIT = 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: I.O IL 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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY C xb 5D 11 D_Q <br /> COUNTY# JURISDICTION# �OCN.{FAI G�NEAe �y <br /> LOCATIONCODE OPTIONAL ICENSUS TRACT# -OPTIONAL - SUPVISOR-DISTRICTCODE -OPT) NAL <br /> D/ Ga z3 IF <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO AT N ONLY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORJJA�R6 <br /> OO6 <br /> SGC . 52c�\ `.o 1-4 8 <br />