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4moo^ e <br /> STATE OF CALIFORNIA c <br /> 3P <br /> STATE WATER RESOURCES CONTROL BOARD W m� ue <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A � <br /> C�t,^OMN�^ <br /> COMPLETE THIS FORM FOR EACH F.AeII5rrY1SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT L] 4 AMENDED PERMIT [::] e TEMPORARY SITE CLOSURE /To <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME, / NAME OF OPERATOR <br /> ADDRESS NEAREST CR OSS STREET PAflCELAIOPTgNAu <br /> 0 0 : / / a S{ <br /> CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> C da / 20 9y6 sic <br /> ✓ BOX CORPORATION I�INDIVIDUAL D PARTNEflSHiP LOCAL-AGENCY O CWNTY-AGENCY STATEAGENCYFEDERAL-AGENCY <br /> TOINWCATE DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR / = 1 IF INDIAN RESERVATION i OF TANKS AT SITE E.P.A. I.D.%(aprbnalJ <br /> O 3 FARM O 4 PROCESSOR E-m/5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FI <br /> on JUA " aO - 2 V, - / <br /> NIGHTS: NAME(LAST,FIRST) PHONEa WITHAREA CODE NIGHTS: NAME(LAST.FIRST) <br /> I PHONE 4 WITH <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 15' E A/3n /no /i7C - <br /> MAILING OR STREET ADDRESS ✓ �r O INDIVIDUAL E::] LOCAL-AGENCY O STATE-AGENCY <br /> O, PDX 95-7 CORP RAT'ON = PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 4S - -S4d <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ci~ RS ZY <br /> MAILING OR STREET ADDRESS ✓ hoa bli#icab (] INDIVIDUAL D LOCAL-AGENCY Q STATEAGENCY <br /> CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIA ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Im Nindk I SELF INSURED 12 GUARANTEE O 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDT =B EXEMPTION = W 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: L 0 I.EJ III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL ICANTS NAME(PA INTED&S IGNATURE) APPLICANTSTIRE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1ZT0 p O ACI F li O <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CO -OP710NAL <br /> D 0?3 .3a3 <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(5-91) FOROD33A-5 <br />