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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Com" ry D <br /> COMPLETE THIS FORM FOR EACH FACILfTY!SITE <br /> MARK ONLY �i 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGED; INFORMATION 7 7(OMIDNALI <br /> CLOSED S <br /> ONE ITEM j 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME `` � NAME OF OPERATOR <br /> P K <br /> ADDRESS NEAREST CROSS STREET PARC-EL <br /> bf £ Co . v/e'.1 <br /> CITY NAME STATE IJP CODESITE PHONE 4 WITH AREA CODE <br /> TOINDIICCATE p CORPORATION p INDIVIDUAL p PARTNERSHIP p LOCAL-AGENCY p COUM AGEWY p STATE-AGENCY p FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR p ✓ IF INDIAN is OF TANKS AT SITE E.P.A. L D.♦(9pb*WJ <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST,FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> cCr vVei 7ldK-�/ 2oel-L/ - 77 <br /> NIGHTS: NAME(LAST,FIRST) I PHONE F WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONF r WITH ARFAc <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME _ CARE OF ADDRESS INFORMATION <br /> LJi Se ccv2 &-e/ <br /> MAILING OR STREET ADDRESS ^^�� /I-- pp � ✓ Oox bMrar p YIDM M AL p LOCALAGENCY p STATEAGENCY <br /> /96 S 5 ZJ. rQ CS /T-!T/ p CORPORATION p PARTNERSHIP p CMNMT AGENCY p FEDERALAGENCY <br /> CITY NAMESTATE ZIP CODE PHONE 4 WITH AREA CODE <br /> Sic cAlev-L C9- Y 3 ua— <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 'ZI: <br /> MAILING OR STREET ADDRESS ✓ mx brbcNN p IMNVIDUAL p LDCA4AGENCY p STATEAGFNCY <br /> p <br /> CORPORATION p PARTtERswP p COUNTYAGENCY p FEDERALUaENLY <br /> CIT'NAME STATE I LP CODE PHONE 4 WITH AREA CODE <br /> IV. BOARD GE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK 0 a 0 3 d- G <br /> V. PETROLEU NAFCfALA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> m bvN[aN p t SELF-INSURED U 2 GUARANTEE ` 7 MSURMCE r SURETY BOND <br /> p 5 LETTER OF CREDIT p 6 EXEMPTION `I 95 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Leoal notification and billing will be sent to the tank owner unless box I or II is ch ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= It. UL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PER.IURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY P JURISDICTION P FACILITY s O LT NM t 0 <br /> F?717 F771 6- 1 S a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT; -OPTIONAL I SUPVtSOR-DISTRICT CODE -OPTIONAL <br /> 3� I Co 33s 3h/?_5- <br /> THIS <br /> 3 sTHIS 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(591) FOROM 5 <br />