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'`/ STATE OF CAUFORMA oum'm <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY U I NEW PERMIT L G RENEWAL PERMR - S-CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> CNE ITEM n 2 INTERIM PERMIT ,�; A AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACT NFORMA�N&ADDRESS-(MUST B ETED) <br /> pea AGILITY NAME I NAME UF OPERATOR <br /> ADORESS NEAREST CROSS STREET PARCEL.(OPTIONAy <br /> 75 0C) // I GAI41S r _ A✓ i2 <br /> ry NAAE / <br /> STATE ZIP CODE SITI 1-5 -374 fE PHONE N=WITH AREA CQCE <br /> ✓ SOx PoPATXON p WDIVOUAL p PARTNERSHIP Q LOCAL�AGENCY p COUNTY-AGENCY Q STATE-AGENCY pOFFmEEpAL Y <br /> TO INDICATE 06TRIT5 <br /> TYPE OF BUSINESS EVI GAS STATION Q 2 1 ✓ IF INDIAN 14OF TANKS AISITE I E.P.A. L D.a ro WWI <br /> O FARM GI A PROCE R OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTA6T PERSON (SECONDARY)-optl <br /> C S: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) / �< <br /> D C 26 — / D i�Le,;.,rk <br /> NWHTS: NAME(LAST,F ST) P14ONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PHONE.WITH ARc <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME NL � <�- A% P. <br /> AJA` 'V A CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADCRESS ✓ ba.o VMKAN p INDIVIDUAL Q LOCAL-AGENCY p STATEAGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNrY.AGENCY p FWEMLAGENCY <br /> CITY"ME STATE ZIP CODE PHON WITH AREA CODE <br /> III ANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> E OF OWNER CARE OF ADDRESS INFORMATION <br /> C_ <br /> MATING OR STR 'eT ADDRESS ✓ O amm,N p UQIVIDUAL Q LOCAL-AGENCY Q STATE- <br /> Z IVTsv f-CORPORATION p PARTNERSHIP Q COUNMAGENCY p FEDEPAI <br /> Try NAME STATE ZIP CODE <br /> � 9s PHONE a y3WITH AREA CODE <br /> s7� a -�� <br /> IV. RD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) H A <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD($) USED <br /> ✓pan yA Q I SELFJNSURED Q 7 GUARANTEE Q 7 INSURANCE Qt <br /> p 5 UETTEROFCREOT p e EXEMPTION Q S OTHER <br /> A. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box r II's c <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN CORREAPPLCANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONT 4YNLOCAL AGENCY USE ONLY <br /> COUNTY# /� iy !�—JURISD�ICTION a 01 <br /> LOCATION CODE -OP770M, CENSUS TRACTS -OPITIONAL SUPVISOR-DISTRICT CODE -OP770ML <br /> 4 S <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-BI) /� / PONO0034-5 <br />