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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> �'� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A �� y° <br /> y . ,.a . <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT ❑ 5 ANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT O d AMENDED PERMIT LZ S TEMPORARY SITE CLOSURE -..3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> S, C <br /> CIN NAMESTATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> Loop CAI/ BOX <br /> gfs�O <br /> TO INDICATE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY E:J FEDERAL-AGENCY <br /> DISTRICTSTYPE OF BUSINESS 3 GAS STATION Q 2 DISTRIBUTOR � ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.0.S(oorknal) <br /> RESERVATION <br /> Q 3 FARM 0 d PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,F/IRST) - PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> p , bi.�ic... ,jG ,F L(l1 'd 3d--7`fN7 SAN <br /> NIGHTS: NAME(LAST,FIRS PHONE S WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> A Avg- S x-.o <br /> PHONE#WITH AREA CODF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME _ CAREOFADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓boxblREkaM INDIVIDUAL AL-AGENCY <br /> Q STATE-AGENCY <br /> _ CORPORATION PARTNERSHIP COUNrYAGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE q PHONE S WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SH rn1 G 5 <br /> MAILING OR STREET ADDRESS- ✓box binOkaN D INDIVIDUAL D LOCAL-AGENCY STATE AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME - STATE ZIP CODE PHONE%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 - y l 3 07 (p <br /> V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ :7.,dkate f I SELNNSURED Q 2 GUARANTEE ED INSURANCE (]A SURETY BONG <br /> O 5 LETTEROPCREDIT 11 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.O II. 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 a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTVx JURISDICTIONS FACILITY# J fBCK�GC <br /> 3 .9, =I- �/ T <br /> LOCATION CODE OPTIONAL (CENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> .1�1 3 3 C> y3 <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 0291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR W 33A-Hf. <br />