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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ty .• "'�`�; <br /> /- UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH CILITYISITE <br /> MARK ONLY 1 NEW PERMIT O RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT Q a AMENDED PERMIT a TEMPORARY SITE CLOSURE Q <br /> 1. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> �� S e.rr ^7ZA-N5 oK-T <br /> ADDRESS NEAREST CROSS STREET PARGELr(OPTIONAU <br /> /3 L✓/ <br /> CITY NAM STATE ZIP DE SITE PHONE r WITH AREA CODE <br /> Ca 312,01_ 01-Z--7V90 <br /> CORPORATION PTNERSHIP LOCAL-AGENCY Q COUNTYAGECY STATE AGENCY FEDERALAGENCYiOINOCATE <br /> DISTPoCTS <br /> r��F <br /> USINESS Q IbAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN- OF TANKS AT SITE E.P.A. L 0.+(aPlimap <br /> - -- <br /> RESERVATION + <br /> (J-1 S FARM a PgQOESSo0. -5.➢TREK- OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: ME(LAST,FIRST) PHONE a WITH AREA CODEI YS: NAME(LAST.FI <br /> NIGHTS: NAME(LAST,FIRST) PHONE r WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PWCNF r WITH AREA COOF <br /> II. PROPSRTY OWNER INFORMATION• UST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> P <br /> r <br /> MAIL.NG OR STREET ADORE I ✓ O EhtlFAO 11 !WVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> O I =CORPORATION = PARTNERSHIP O COUNrYLGENCY 0 FEDERAL AGENCY <br /> CITY NAME Tr 1 I $TATE ZIP CODE PHONE•WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEOFCWNER /. CARE OF ADDRESS INFORMATION <br /> 90,me �h <br /> MAILINGO T\EET ADDRESS ✓ OOF o�IOIC2lA Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> O CORPORATION Q PARTNERSHIP O COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 d questions arise. <br /> TY(TK) HQ F4_74 - D Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ,� eol nildcm Q I SELFINSURED Q 2 GUARANTEE Q 1 INSURANCE Q 1 SURETY SONO <br /> f� 5 LEITEROFcREDR Q P EXE11PnON O N 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Q IL= IN.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TIRE DATE MONTWOAYNEAR <br /> S- <br /> LOCAL AGENCY USE ONLY Y.k/ <br /> COUNTY a JURISDICTION R FACILITY 0 <br /> ® 5 U = 10 ° a <br /> LOCATION CODE -OPTgNAL ICENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPT,CNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(591) FOROWJAS <br />