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STATE OF CALIFORNIA y''c �^ <br /> STATE WATER RESOURCES CONTROL BOARD w��� <br /> !l UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , �,e - <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OB OR FACILITY NAME NAME OF OPERATOR <br /> f "— <br /> AD RESG NEARES CROSS ST EET PMCEL#(OPTK)NAL) <br /> CITY NA STATE ZIP DE SITE PHONE s WITH AREA CODE <br /> K� CA <br /> T I/ box PARTNERSHIP E:—]CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL DISTRICTS O COUNTY-AGENCY D STATE-AGENCY (]FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplienal) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> NAAMEOFOWNER <br /> T PERSON (PRIMARY) EMERGENCY <br /> E LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,F T) D <br /> VI 0 <br /> ME(LAST,FIR PONE#WIT AEA CODE NIGHTS: NAME(LAST,FIRST) <br /> II d PHONE WITH AREA COOP <br /> ERTY OWNER INFORMATION- MUST BE COMPLETED <br /> - CARE OF ADDRESS INFORMATION <br /> �'EE AD ESS y� ✓ bwbinlla4 (] INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> i.. L Q CORPORATION PARTNERSHIP I� COUNTY-AGENCY l�FEDERAL-AGENCY <br /> I STATE ZIP DE _ PHONE#WITH AREA CODE <br /> /T- 5a) S -lp3R INFORMATION-(MUST BE COMP <br /> WNER a CARE OF ADDRESS INFORMATION <br /> G - ' Cecch'iNl dQ <br /> MAILING OR STREET ADDRESS I ✓ b>Ibindmm E::] INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 000 O CORPORATION XPARTMERSHIP D COUNTYAGENCY I= FEDERAL-AGENCY <br /> CITY NAME STATE ZIP DE PHONE# TH AREA CODE <br /> i:AtbCl4 — <br /> TY(TK) HO 4 F4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa binEbaY 1 SELRNSURED 2 GUARANTEE lLj 3 INSURANCE d SURETY BOND <br /> O 5 LETTER OFCREDIT 6 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.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) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY Do/ <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CO -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR- TRICT CGDE -OPTIONAL <br /> 3. <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) / F OW3A-5 <br /> 9=.Sv Lt LQ �. / off" ?— 9 �� <br /> t-SScc.a, <br />