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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> G <br /> COMPLETE THIS FORM FOR EAJCH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME. NAME OF OPE TOR <br /> f Oki <br /> ADDRESS NEAREST CR SS STR T PARCEL#(OPTUNAU <br /> E. Cfigrkr �iaNc7-/.Of-a - <br /> CITY NAME � � STATE ZIP CODEO� SITE PHONE#WITH AREA CODE <br /> BOX CA : zo:AJ <br /> T NOCATE O CORPORATION 0 INDIVIDUAL [=1 PARTNERSHIP l]LOCAL-AGENCY Q COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(apamal) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> [NIGHTS: <br /> AYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> OL?- -,266 <br /> 2 WITH AREA CODI7 <br /> NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHQNP&WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME M CARE OF ADDRESS INFORMATION <br /> Y� <br /> MAILING OR STREET ADDRESS ✓ boabmdbak INDIVIDUAL I1 LOCAL-AGENCY Q STATE-AGENCY <br /> 42 2 a4e O CORPORATION O PARTNERSHIP O COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> Gil 209-Asp-Z 668 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ac <br /> MAILING OR STREET ADDRESS DosbmGicab E-1 INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP COUNTY.AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE <br /> FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -L✓ I (�l <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa bir&ms E�]1 SELFINSURED =2 GUARANTEE [�] 5 INSURANCE Q 4 SURETY BOND <br /> 5 LETTEROFCREDIT V6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ It.v 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 MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> C�OU�NTY# JURISDICTION# FACILITY# <br /> LOCATIONOODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL p <br /> 4 /Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) - FOROMA 5 <br />