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STATE OF CALIFORNIA a <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A d� "° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �'d o <br /> MARK ONLY F--1 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTL TE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O S TEMPORARY SITE CLOSURE �a <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> G v <br /> ADDRESS NEA�RIIST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE ITE PHONE#WITH AREA CODE <br /> GUa-r CA 9 Z41D �#'�t� 33l - 7r 77 <br /> ✓BOX O CORPORATION E3 INDIVIDUAL ED PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> Naemerd USTbaplb9cagM,cmWeMblbwng.r dsPemiwol&b6n,section&offawfi o Ow Na UST <br /> TYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN NOF TANK AT SITE E.P.A. L D.#(optional) <br /> 3 FARM 4 PROCESSOR OTHERRESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LASp FIRS PON WITH AREA CODE DAYS: NAME(LAST,FIRST) PRONE N WITH AREA CODE <br /> S v l �ilL racy-i �3/— � / <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bosbheleata 0INDMDUAL Q LOCAL AGENCY STATE-AGENCY <br /> /}/. lj bGy,,,E .� ' O CORPORATION O PARTNERSHIP ED COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WIT�AREA CODE <br /> GD4 � 9 SZ�� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to iiNiote INDIVIDUAL (] LOCAL-AGENCY O STATE-AGENCY <br /> �' 6o�Jcc� - O CORPORATION D PARTNERSHIP Q COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PH NE 0 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4--[4--l- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> r be.M i6ceM = I SELF-INSURED O 2 GUARANTEE Q 3 INSURANCE =A SURETY BOND 5 LETTEROFCREDR O S EXEMFnON 0 T STATE FUND <br /> O#STATE FUND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE FANO N CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O NN 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: 1.Q II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND C RRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> C�(OODUTINTY�# JURISDICTION N FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPT,iXAL SUPVISOR-DISTRICT CODE-OPnONAL <br /> SU 2 0 (0 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS"1IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORK THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO ;TORAGE TANK REGULATIONS <br /> FORM A(6-95) -�wi <br />