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STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> r * COMPLETE THIS FORM FOR EACH FACILITY/SITE oar" <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED S1TE <br /> ONE REM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE 01 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DeJgA�T AME N OF OPEMTOR tLcZ <br /> / O.3 <br /> AOOflE S N ARESTCR�O�--SS7S TREET rr PARCEL#(OPTIONAL) <br /> O �� T\ G <br /> CITY NAME STATE ZJQ„CA SITE HONED WITH AREA CODE <br /> To Lq CA oqzq <br /> T 1NDIICCAT <br /> 0E EW160APORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'N ovmer of UST Is a public agency,oanplete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPEOF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION a OF SITE E.P.A. I.D.#(opNmel) <br /> 3 FARM Q 4 PROCESSOR ®OTHER ORTRUSTLANDS �. <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 14, <br /> NI S: NAME(LAST PHONE xWITH AREA CODE IGj NAME(LAST,),•L.J T ST) PHONE#WITH AREA CO E <br /> co r A/c.JJ z�-isZ-S�S6 <br /> II. PROPERTY&NER INFORMATION• MUST BE COMPLETED <br /> NAME/ T_ CARE OF ADDRESS INFORMATION <br /> PR I <br /> MgLJ1NpS�JRep7TAD/D SSS ✓IarblMiods INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> F J p lJ �(� CORPORATION PARTNERSHIP (] COUNrY.AGENCY FEDERAL-AGENCY <br /> C ME l STATE I ZIP CODE 1,PHONE#WITH AREA CODE <br /> �N Zo —� <br /> III. TANK OWNER INF RMATION•(MUST BE COMPLETED) <br /> NA�.QSq'yyEi Tis CARE OF ADDRESS INFORMATION <br /> :T M pY11pLLRRSTTR ETADD ESS ✓ hox kale = INDIVIDUAL ED LOCAL-AGENCY D STATE-AGENCY <br /> A,J J CORPORATION = PARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP DE PHON WITH AREA CODE <br /> ,ZnZz 4,y/ 9 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIA RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓be%b� 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE O 4 SURETY BOND <br /> O 5 LETrEROFCREOIT 0&EXEMPTION gg OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless 12px 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.= III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(`PR�ITNTED&SIGNED) 19 OWNER'.CTITLE ----T—()ATE MONTWDAYNEAR <br /> 2C1'"L S 'r��tJ'yFf_ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# - FACILITY• <br /> MI = ® 5� � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OIPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 01 1 1 591z <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK TIONS <br /> FORMA(30113) ri(/ FORmmw <br /> . • 2�i71 <br />