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• 6aU- e <br /> STATE OF CALIFORNIA <br /> r• x <br /> STATE WATER RESOURCES CONTROL BOARD 3� V <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a� <br /> c �S�IA Y tin <br /> rwL1•CJn Nt� <br /> COMPLETE THIS FORM FOR EACH FACILrrY/SITE <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE /^+w <br /> 1. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME� tt--77 NAME F OPERATOR <br /> C1� <br /> [ �ry P-� L7 t 1 p"'-1Qr �N �C �, <br /> ADDRESS NEAREST CROSS STREE PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE <br /> SITE PHONE#WITH AREA CODE <br /> f'IPr'C�t CA <br /> BOX <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY <br /> OSTATE-AGENCY [__1FEDERAL-AGENCYDISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SIT�EP, I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE;WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHC]N <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> W�Tlj AREA COD <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa Windicale [] INDIVIDUAL [� LOGALAGENGY OSTATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP [� COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF OWNER CARE OF ADDRESS INFORMATION ,+ <br /> C c P I USN car / era CORPORATION e, � <br /> MAILING OR STREET ADDRESS ✓ box to indioale � pIVIDUAL LOCAL AGENCY � STATE-AGENCY <br /> 0 / 0 <br /> [] PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CI NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> CW 1 Q52o/ <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 FINANCI RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate LZ I SELF-INSURED 2 GUARANTEE [::] 3 INSURANCE 0 4 SURETYBOND <br /> 171 5 LETTER OF CREDIT 6 EXEMPTION E:1 0 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 checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLCNG: I.0 II.❑ R. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> EIIYLOJ�al mcl'rox <br /> LOCATION COg OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 7 .Z 3, 3zs` 7 s � <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) <br /> FOR0033A-5 \ <br />