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STATE OFCALIFORNIA o <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD i4 ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A "aeffi as <br /> COMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY 0 t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 51 <br /> SITE <br /> ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME NAME OF OPERATOR <br /> Per v <br /> ADDRESS � � NEAREST CROSS STREET PARCELs(OPTIONAl) <br /> CITY NAME / � STATE ZIP CODE SITE PHONE S WITH AREA CODE <br /> sA_44/G f(/n <br /> CA <br /> 25-W ce <br /> TDIN BOX O CORPORATION =INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY AGENCY D STATE-AGENCY EFEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS (] I GAS STATON 0 2 DISTRIBUTOR / 0 ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.s(opllmaQ <br /> IJ�Q/ RESERVATION <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 0'a 57 A'1/0 / 0 — fo —fp O(iPHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIAT) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> r <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> B /jv S <br /> MAILING OR STREET ADDRESS 4 ✓ 6ox I0 cm =1 INDIVIDUAL LOCAL-AGENCY Q STATE AGENCY <br /> f Z Y A•'f 0/I/C2 . =j CORPORATION E-I PARTNERSHIP L�I cOUNrY#GENCY E=1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> lCf F4 R'00 S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _ S-"— 424 4I{ �— <br /> MAILING ORSTREET ADDRESS ✓ boa bindbas E__1 INDIVIDUAL E_j LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F41 4 1- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ Eos miMkale (] I SELF-INSURED [D 2 GUARANTEE Q 3 INSURANCE E=1 4 SURETY BOND <br /> O 5 LETTEROFCREDIT [:j6 EXEMPTION N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1, s checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.F-] III.O <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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY Lae, Lev <br /> COUNTY x JURISDICTION N FACILITY u PL.P gOJ�y <br /> 39 1JJ1 96 <br /> LOCATION CODETIONAL ICENSUS TRACTS -OPTIONAL SUPVISOR-DISTRICTTCOODE -OP <br /> OPTIONAL <br /> U 3f'0 323 <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 AII2-9I) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND TORAPE TANK REGULATIONS <br /> FOROW3AR6 <br />