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dya e <br /> STATE OF CALIFORNIA . t <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> COMPLETE THIS FORM FOR EACH LITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:j 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT Q 4 AMENDED PERMIT D S TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> P7? we6e-i S � A 1(LOS- <br /> ADDRESS NEAREST CROSS STREET PARCELR(OWgNAW <br /> L/ N . ��o�� 0�,u" <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> v Box 51,Zv c% Ar7n 0 CA S-d-vl - <br /> TORINCATE p COflPO ATION INDIVIDUAL Q PARTNERSHIP Q LOCAI.AWMY Q CWNryAGENCY Q STATE-AGENCY Q FEDERALA%NCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTORO IF INDIAN A OF TANKS AT SITE E.P.A. L O.#(OPI <br /> RESER✓ VATION <br /> Q 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> [NIGHTS: <br /> AYS: NAME(LAST RST) Pr ONE 0 WITH AREA CODE GAYS: NAME(LAST,FIRST) <br /> �rrl <br /> NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA QQQ,: <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ge.-fru dP <br /> MAILING OR STREET ADDRESS IbicaN <br /> JJ�� INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> .3 75-7 L—C7/�P OflPO iDN p PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAMESTATE ZIP CODE PHONE A WITH AREA CODE <br /> 4-0 <br /> p <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER / CARE OF ADDRESS INFORMATION <br /> 44UL3 <br /> MAILINGORSTREET ADDRESS ✓ WxbiMiem p INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> p CORPORATION Q PARTNERSHIP Q CouNryAaENcY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Cal)(916)323-9555 if questions arise. <br /> TY(TK) HQ F4747-[22 <br /> a SOL/ <br /> V. PETROLEUM UST FINANCIA SPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ppy bIMKY# 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q I SURETY BONO <br /> Q 5 LETTER OF CREDIT Q I EXEMPTION Q%OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is check <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O IL - 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION# FACILITY A' <br /> 3 1 1 1-2 `/ 13 TZI <br /> LOCATION CODE CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT <br /> E� CODE -OP770NAL <br /> / 3,Fb 1 02 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORB033A5 <br />