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v f <br /> STATE OF CALIFORNIA ` <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD it <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOO EACH ACILRYISITE <br /> MARK ONLY ❑ t NEW PERMIT 3 RENEWAL PERMIT FfrI5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL pD SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE 1 9 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> J i <br /> ADDRESS NEAREST CROSS STREET PMCEU(OPTIONAL) <br /> o� S, Z=wk�o Go�2 4vim' <br /> CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> Gpp— CA Z <br /> '/ 80x CpRP01U 0 INDIVIDUAL =PARTNERSHIP O LOCALAGENCY O COUNTY AGENCY D STATE-AGENCY O FEDEML-AGENCY <br /> TOINDICATE DISTRICTS <br /> TYPE OF BUSINESS E7f T GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.#(optional/ <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) 74!"1"WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> i - /44PHONE a WITH AREA COO <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREACODE �Nr.HTS: E(LAST,FIRST) PHONE#WtTH AREA CODE <br /> II, PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> y, �,7 CORPOMTION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP IYHONE WITHAREACODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OW ER CARE OF ADDRESS INFORMATION <br /> en <br /> MAILING OR STREET ADDRESS- ✓ Eoa kale O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 2737 Gviy ti ORPORATION O PARTNERSHIP O COUNNAGENCY O FEDERAL-AGENCY <br /> CITY NAME EA CODE STATE ZIP CODE HON #WITH AR <br /> SS IGJ-Nry iL/�� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-p4 -F] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlkate E:::] 1 SELF-INSURED (] 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> =5 LETTEROFCREDIT 6 EXEMPTION O 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.❑ 11.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT a <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY## �"Ai✓P �U <br /> r I -- I / <br /> )47/ <br /> � I <br /> LIXO'ATION CODE OPTIONAL (CENSUS TRACTx -OPTIONAL SUfaP,nR-DISTRICT CODE -OPTIONAL e- 7- 11,61q 6 q <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION-/'FORM B,UNLESS THIS IS ACHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12.911 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ` FORW33AR6 <br />