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Yt60Ja .. C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT [—+-1'CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE a <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORfACILIN NAME ^ NAMEOF OPERATOR .n <br /> LC WItA V PA/11YL�L4-I <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Z�5 k 1 <br /> CITU NAME STATE ZIP CODE SITE PNONEk WITH AREA CODE <br /> CA 5-1w / - Z57 <br /> TOINDICATE CORPORATION DIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY <br /> OCAL- G NCY D COUNTY-AGENCY O STATE-AGENCY Q FEBERAL-AGENCY <br /> DISTRITS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOROTHER OR TRUST LANDS y <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COD! <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME 6 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS' ✓ box bindimiw 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> 6 Id O CORPORATION l= PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> NAkCITY STATE ZIP ODE PHONE#WITH AREA CODE <br /> V!No�v4rc-2 eq <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxbiMiCa19 OINDIVIDUAL LOCAL-AGENCY 0STATE-AGENCY <br /> CORPORATION E=1 PARTNERSHIP O COUNTY-AGENCY I= FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4 4 -n2. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm mlMicale I 1 I SELF INSURED L )GUARANTEE 0 3 INSURANCE [:j 4 SURETY BOND <br /> 5 LETTER OF CREDIT U 6 EXEMPTION 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: 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 NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY# <br /> 55 T3 <br /> LOCATION CODE OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT 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 /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION <br /> r FOP0033AR <br /> V <br />