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­ (/ ;4� /',0 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �4npn N`r <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 0 7 PERMANENTLY SED <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT F] S TEMPORARY SITE CLOSURE 19 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAM OF OPERATnR G/ - <br /> oti F 7fe <br /> ADDRESS%A/ NE9jC23 03S <br /> CITSTREET PARCEL#(OPfgNAL) <br /> CITY ST7A'CC/EAJrK/c�A•VZ���D� SITE PHONE#WITH EA CO�/ _ <br /> ✓ Box ORPORATION �INDIVIDUAL D PARTNERSHIP O LOCAL-AGENCYD COUNTYo1GENCY 0 STATE-AGENCY FFDERALAGENCV <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTORl0 RESERVATION/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.A(optimal) <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CO TACT PERSON (SECONDARY)•optional <br /> DA ' NAME(LAST.FIRST) ;OE#WITH AR_ ODEOf-S-1 <br /> DAYS: NAME(LAST,FIRST) <br /> /VAS '//! <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 9 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME n ! CARE OF ADDRESS INFORMATION <br /> MAI GOR3 EET ADDRESS /J J `�Wyb� INDIVIDUAL O LOCAL-AGENCY I� STATEAGENCY <br /> �OxD' O RPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL#GENCV <br /> CIN yAM S gJF.,, ZI1175 PHONE -AREA <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N�F OWNER CARE OF ADDRESS INFORMATION <br /> S/dN <br /> MAI ( As; ETADDRVS. `�M 0 INDIVIDUAL O LOCAL-AGENCY I� STATE AGENCY <br /> VO j RPoRATION L-1 PARTNERSHIP COUNTRAGENCY F] FEDERAL"NCV <br /> CITYNAMESTATE ZIP PHONE#WITHAREA CODE <br /> S O � <br /> GS ^/ /-rdl (!J Jc"J`Vn Yi/ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4P4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEME OD(S) USED <br /> ,/boll blMbaN I� I SELF-INSURED O 2 GUARANTEE NISURANCE 0 A SUW BONG <br /> D 5 LETTEROFCREOT (]6 EXEMPTION [-199 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.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PR INTED&SI TUR APPLICANTS TIRE DATE MONTH/DAYNEAR <br /> ��N Zd // <br /> LOCAL AGENCY USE ONLY <br /> COUNTY IT I , � I JURISDICTION N FACILITY# O <br /> 7� ✓(/ v/ <br /> LOCATION CODE - T N L CENSUST CT�1 -OPTIONAL SUPVISOR-D TRICT CODE -OPTIONAL <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 /> FOR0033A 5 <br /> FORM A(591) _ <br />