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STATE OF CALIFORNIA �� ��� <br /> STATE WATER RESOURCES CONTROL BOARD :d� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE m <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACILITY NAM / �� NAME OF OPERATOR <br /> ADDRESS / —(/gyp( N RaTCROS$fTREET PARCEL IIOPT(OPTIONAL) <br /> 7S <br /> CRY NAME STATE ZIP;pE , SITE PHONE N WITH AREA CODE <br /> I pC CA �// <br /> ✓BOX XCIRPORATION 0 INDNIOIIAL E:) PARTNERSHIP O LOCAL-AGENCY D COUNTY.AGENCY' O STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> '6 ownxd UST B s pubk sAeoKY.W^VMb Me fakwnq woe d supervimrd dvWm.seWm orWa Md opeoles fire UST <br /> TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION A OF TANKS AT SITE E.P.A. I.D.#(oplgneq <br /> ❑ 3 FARM �4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: E(LAST,FIRST) PHONE# ITH AREA CODE DA S: NAME(LAST, RST) PHONE#WITH AREA CODE <br /> 3 e - r -t <br /> NIGHTS: NAME(UST,FIRST)" PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> O/ <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> C EOFADDRESS INFORMATION <br /> SSOG Gyb <br /> MAIIJNG OA/$7/�EET ADDRE ✓ box W kKIE 9 O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> uvv I1 CORPORATION PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY N STATE ZIP CODE PHONE#WITH AREA CQQE <br /> C1,a 83 S v 0z6 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER Gtr CARE OF ADDRESS INFORMATION <br /> . J. <br /> MAILING OR STREETAD SS ✓ boxb a l� INDNIDUAL LOCAL AGENCY STATE-AGENCY <br /> �. KCORPORATION PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NvWIE STATE ZIP CODE PHONE#WITH AREA COD <br /> a c C 3 6 - a0 <br /> IV.BOARD OF EO LIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HO 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(UST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Su to Ys&,�# O 1 SELF-NSUREO = 2 GUARANTEE 0 3 INSURANCE O<SURETY BOND Q 5 LETTEROFCREDIT 0 6 EXEMPTION O T STATEFUND <br /> O8 STATE FUND&CHIEF FINANCIAL OFFICER LITTER O6 STATE FUND&CERTIFICATE OF DEPOSIT OtoLOCALGOVr.MECHANISM = 660THER <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: 1.❑ II.Ej lIIx <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION W PAQjklelrw <br /> I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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 /> OWNER MUST FILE THIS FOP STH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRr STORAGE TANK REGULATIONS <br /> FORM A(E95) <br />