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STATE OF CAUFORMA ` <br /> STATE WATER RESOURCES CONTROL BOARD v ` '`•J•~-r��� <br /> C/ UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> D <br /> n, <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW.PERMIT ❑ O RENEWAL-P&RMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLO ` o'^E <br /> ONE ITEM ❑ 2 INTERIM PERMIT E:1T A AMENDED PERMI6 TEMPORARY SITE CLOSURE <br /> 0 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME S>, Vr„ NAME OF OPERATOR <br /> ADDRES v NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> CITY NAM <br /> STATE ZIP CODE SITE PHONE 6 WITHAREACOOE <br /> ✓ BOX <br /> CA 6 27 Sa <br /> TOINDICATE �=CORPORATION C INDIVIDUAL I I] PARTNERSHIP Q LOCACAGENCY Q COUNTY AGENCY (] STATE AGENCY (] FElERAL#GENCY <br /> OLSTRICTS <br /> TYPE OF BUSINESS ❑ 1 OAS STATKSN ❑ 2 DISTRIBUTOR ✓ IF INDIAN AOF TANKS AT SITE E.P.A. 1.0.A(gaTimWJ <br /> ❑ O FARM G' • PROCESSOR S OTHER a RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME(LAST,FIRST( PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE r WITH AREA CQD- <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> 5 141 —7X '-r/G ' / / �y�{ OF AOORESS INFORMATION <br /> MAILING OR STREET ADDRESS ' � Ou� ✓ bw bNtlkal6 Q INDIVIDUAL (_f LOCAL AGENCY <br /> O5 <br /> TATE AGENLY7 CONPORATION = PARTMgSHP <br /> CITY NAME COUNry4cENCY FEDERAL-AGENCY <br /> STATE ZIP CODE HONE A WE4 AREA CODE <br /> Ill. K OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OW CARE OF AUUHJ SS INFORMATION <br /> MAILING OR STREET ADDRESS ---- —' ✓ Ov bvbraY Q INDIVIDUAL <br /> a LOCALAGENCY 0 STATE-AGENCY <br /> CITY NAME O CORPORATION 0 PARTNERSHIP Q COUMY-AGENCY Q FEDERAL WENCY <br /> STATE ZIP CODE PHONE 6 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - p <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Em biles (] 1 SELF-INSURED 02 GUARANTEE (] 7 INSURANCE <br /> O 5 LETTER OF CREDIT =6 EXEMPTION 99 OTHER 0 A SURETY BONG <br /> O <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank o er unless x I or II 6 c ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADORES$SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L IL❑ ILL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNO E,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRNTED a SIGNATURE) APPLICANTS TITLE DATE MCNTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY r 3� ,('�7/�Q JURISDICTION a� ® StJ 1 ()3 r Com❑ U QA�LmF O <br /> LOCATION CCOE -CP 7'pNAL (CENSUS TRACTS •G°TIONAL SUPVISOR-DISTRICT COOE .OPTIONAL <br /> a <br /> THIS PoM <br /> FORMA(S O) UST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> FOR6017AS <br /> L. <br />