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STATE OF CALIFORNIA �� _� <br /> STATE WATER RESOURCES CONTROL BOARD + ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A ^nffi "s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °�r„o„�,� <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACTYTY NAME NAME OF OPERATOR <br /> DonJJ GoLVi� <br /> ADDRESS <br /> 2 5- 5. GQ NEAP CROSS STREET PARCEL s(OPfDNAU <br /> CITY NAME STATE ZIP CODE SITE PHONE It WITH AREA CODE <br /> �Q CA <br /> TO <br /> I/ BOX <br /> INDICATE 0 CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY AGENCY' 0 STATE-AGENCY' Q FEDERALAGENCY' <br /> N avna d UST N a public DLSTRIDTS' <br /> p apanuy.wnplae the idbwbB:name d Superviwr d EMlebn,seclkn,IS office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTORRESER✓ IF IVATIONNDIAN s OF TANKS AT SITE E.P.A I.D.s ApSuW/ <br /> O II <br /> 0 3 FARM O d PROCESSOR 6 OTHER Oq TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERG NCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> 14�4— T�o�AG/� s� 6g2—o34Z <br /> NIGHTS: NAME(LAST.FIRST) PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE S WITHAREACODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 1 CAREOFADDRESS INFORMATION <br /> �f�lqu� C�L-vi <br /> [, <br /> MAILING <br /> O STREET ADDRESS ✓box b NgkW INDIVIDUAL O LOCAL-AGENCY QSTATE-AGENCY <br /> orrY SIJZPIOC GpvjQT— O CORPORATION TNERSMP O COUNrV-AGENCY O FEDEMLAGENCY <br /> NAM STA ZIP CODE PHONE s WITH AREA CODE <br /> 692--6 3-7 Z- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF0NER CARE OF ADDRESS INFORMATION <br /> /�i�q� r�TI <br /> MAILING OR STREET ADDRESS l ✓ bel IONNkale INDIVIDUAL LOCAL (]STATE AGENCY <br /> '6,4; 6,c Goth =CORPORATION PARTNERSHIP COUNTYAGENCY 0 FEDERAL AGENCY <br /> CTI-YNAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> 692-03E <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322.9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ 1 SELF-INSURED 1j 2 GUARANTEE 3 INSURANCE D A SURETY BOND <br /> f� 5 LETTER OF CREDIT =B 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: 1.0 IL D III.Q <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(PRINTED B SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY Ts- JURISDICTION <br /> OTU <br /> LOCATIONCODE PTIONAL CENSU3C <br /> O9OPTIONAL N BUPVSOR-DISTRICT CODE -OPTAONAL e— <br /> - <br /> 7— <br /> THIS <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER 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 REGULATIONS <br /> FORMA(393) FOPe003AA7 <br />