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STATE OF CALIFORNIA ~'K '�• un e <br /> STATE WATER RESOURCES CONTROL BOARD �`• c•, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °•�"°"� <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT a 6 AMENDED PERMIT [—] 6 TEMPORARY SITE CLOSURE S� <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> NAME OF OPERATOR L II <br /> O i rA�3 4rJL /�of#a7'� <br /> ADDRESS NEAREST ROSS STREET PARCEL#(OPTX)NAL) <br /> 89y - ehv'k1- aL 6�`iaAv <br /> CITY NAMESTE ZIP CppE zp� ITE PHONE#WITH AREA CODE <br /> 5 2�i H <br /> I/ eox - 2668 <br /> TOINDICATE O CORPORATION D INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY (] STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q I GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opNanaq <br /> 3 FARM Q 4 PROCESSOR OR 5 OTHER RESERVATION D <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: N ME(LAST,FIRST)T) �� HONE#WITH AREA 2668 DAYS: NAME(LAST,FIRST) <br /> [70q I <br /> NIGHTS: Jelqn A E(LAST,FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> IH AREA COQF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME Sam 77 CARE OF ADDRESS INFORMATION <br /> �s <br /> MAILING OR STREET ADDRESS ✓boa blMbaa INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box coxae 0INDIVIDUAL Q LOCAL-AGENCY D STATE-AGENCY <br /> (]CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ baa bbldlGla O I SELF INSURED lam.2�GUARANTEE O 5INSURANCE E=11 SURETY BOND <br /> E:15 LETTEROFCREDT 2 a EXEMPTION 0 W 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: <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> *70pl?IT$/ <br /> L OCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> l z3 . try -57- s Of 1-3-9Z <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) FOROM -5 <br />