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-^ '46 M f <br /> A STATE OF CALIFORNIA ^� <br /> /I STATE WATER RESOURCES CONTROL BOARD W m� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ep �„ os <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE °.�„e,,.^ <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANCE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 0 A AMENDED PERMIT a TEMPORARY SITE CLOSURE 9 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME \\ NAME OF OPERATOR <br /> INIA0,6” ro e/+r —Fe reS-N gr1fr- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONIU <br /> S <br /> CITU NAME �I STATE ZIP CODE 2D7 SITE PHONE#WITH AREA CODE <br /> \tc7 n s- <br /> T 1NDIICCLT <br /> 0E CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY, 0 sTATE-AGENCY' 0 FEmpALAGENCY' <br /> DISTRICTS' <br /> It owner d UST Is a public agency,cortplete the following:nacre of Supervisor of dMsion,section,or office which operffies the UST <br /> TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.s(apliaWl <br /> flESERVATION <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r -cz) Cno0/ c 9 '51 <br /> NIGHTS: NAME(LAST,FIRT) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE WITH AREA CODE <br /> orre o1- . 02 3 - 1'702 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> e re SS a/I'e/ <br /> MAILING OR STREET ADDRESS .1hostllnEtlAN 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> S`1(3 S4.�� GU L #� 2 D CORPORATION O PARTNERSHIP 0 COUNrYAGENCY O FEDERAL-AGENCY <br /> CITY NAME - STATE ZIP CODENE#WITH AREA CODE <br /> Low G4 `f /so3o is 395_ 599/ <br /> Ill, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SS Me / <br /> MAILING OR STREET ADDRESS \ }j ✓ hoc niMicae INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> 5`i F7 �q (JL IZ 3 0 CONPORAT ON 0 PARTNERSHIP 0 COUNTY 0 FEDERAI-AGENCY <br /> CITY NAME 11 STATE ZIP CODE PHONE#WITH AREA CODE <br /> �—si co,,i-p5 Ca 4 SD 3yy] <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HO 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ hMbMkae D i SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE O s SURETY BOND <br /> O 5 LETTEROFCREOIT D B EXEMPTION O m 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.Q II, HE <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&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT'# JURISDICTION# FACILITY# <br /> �ffl 2 (OH <br /> LOCATION CODE -OPTIONA CENSUS TRACT -OPTIONAL 9UPVISOR• TRACT CODE -CIPTpNAL <br /> Q 3u o s 3 aS-5 Y `YL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATKIN- FORM B,UNLESS THIS IS A CHANGE OF SITE Ii1FORMATKIN ONLY. <br /> FORMA(393) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKM <br /> FOR06T31{tT <br /> J/;A4y <br />