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STATEOFCAUFORMA " °• <br /> STATE WATER RESOURCES CONTROL BOARD if <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ),I'' <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATK7N O 7 PERMANENTLp/%? SITE <br /> ONE ITEM 2 INTERIM PERMIT Q d AMENDED PERMIT a TEMPORARY SITE CLOSURE CC <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME 5%PERATOR <br /> R 'o-* -1IlD0 Wrillpe S'f9•50NS INC. 's6os <br /> ADDRESS ^^ L NEAREST CRCSS STREET PMCELI(OPTONAL) <br /> CITY NAME G(•7 STATE `•OZIP CODE SITE E#WITH AREq CODE <br /> Loi% CA A5200 (209 3 5-9 so I <br /> v BOX <br /> TOINOCATE iR CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q CWNrY.AGENCY Q STATE AGENCY Q FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TIW KS AT SITE E.P.A. I.D.a(optional) <br /> RAND <br /> Q 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST pU3T LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONEMaN WITH AREA CODE DAYS: NAME(LAST,FIRST) �ooO ZIZ�b��A cit o*+ 'DuT 24<i�365-9301 AR I'4A tewgt•#C G -'f <br /> NIGHTS: NAME(LAST,FIRST) P E s ITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> a am LDDC �,so'1 bs - 30► " 400 ZZ1—b3VS <br /> If. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Qp0 C-0 . E N-6 Is <br /> MAILING OR STREET ADDRESS ✓bNbMObAY Q INDIVIDUAL Q IOCAL-AGEWY Q STATE-AGENCY <br /> Q.�. o, CORPOMT ON Q PARTNERSHIP Q OOUNTY-AGENCY Q FEDFAALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE IEA <br /> Aate . 90 toe-boa ("JL b_)0 CODE Caa� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> kpt to ro q Co . EH vs <br /> MAILING OR STREET ADDRESS box bkvic m Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-"KY <br /> P.O WT (Cali 9�(CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDEIML#GENCY <br /> CITY NAME <br /> STATE ZIP CODE PHONE WITH AREAc�, <br /> AfZCet� R"12 603 71y b27-SYof <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - O ti S O b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b WIC4, SELF-INSURED l�2 GUARANTEE Q 1 INSURANCE �i a SURET 7 0 <br /> K5 LETTER OF CREW Q 6 EXEw nON Q 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: I.[::] I.O 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) APPLICANTSTITLE DATE M°�'TH YNEAR <br /> lA.� tNV. CD \\ I► ►3d(T1N sly-`11gZ1 <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION a FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OR77ONAL SUPVISOR-DISTRICT CODE -OPT70NAL <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) FOROOIJA-5 <br />