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i w e <br /> -� STATE OF CAUPoRMA <br /> STATE WATER RESOURCES CONTROL BOARD ••�-n��� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Y/ <br /> O <br /> - COMPLETE THIS FORM FOR EA FACILrTYISrTE <br /> MARK ONLY ❑ I NEDLPERMIT ❑ 7 REN IT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY Cl0 u -E <br /> ONE ITEM x INTERIM PERMIT ❑ a AMENOEO PERMIT 6 TEMPORARY SITE CLOSURE G/ <br /> I. FACILITY1SITE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) <br /> D040R FA♦iILITYNAME NAME OF OPERATOR <br /> AOORES <br /> R ^, NEAREST/ROSS STREET PMCEL TIO <br /> ((OPNAU <br /> CITY NAM Pi 1N—• <br /> STATE j ZIP CODE SITE PHONE•WITH AREA COLE <br /> C r 2- Sa <br /> ✓ d0% <br /> TOINOCAT. CORPORATION Q INDIVIDUAL Q PARTNERSMP Q IOCX-'AGENCY Q COUNTY-AGENCY Q STATE AGENCYFEDERALAGENC/ <br /> --06TRICTS Q <br /> TYPE OF BUSINESS I GAS ST ✓Z DISTR15UTOR ^ ✓ IF INDIAN A OF TANKS AT SITE E.P.A. L 0.s(gorivMQ <br /> ❑ O FARM ❑ a PROCESSOR 5 OTHER U RESERVATION <br /> OR TRU57 LANA$ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE A WITH AREA COLE GAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST.FIRST) ._ _ PHONE•WITH AREA COCE NIGHTS: NAME(LAST.FIRST) <br /> �CNP• . c <br /> H. PROPERTY OWNER INFORMATION- MUST BE COMPLETED - <br /> .NAME 5 OFADORESSINFORMATION \ <br /> MAIIN <br /> LGCRSTREETACCRE55 ✓ Q I <br /> b•OnOOIw <br /> 17 NOIYOUAL Q LOCAUAGENCY Q STATE-AGENCY <br /> CITY NAME O > L) I ( Q CORPORATION Q PARTNERSHIP Q CGUNTY.AGENCYJ Q FEOERAL-AGENCY <br /> STATE ZIP CODE HONE.WITH AREA CODE <br /> i <br /> III. K OWNER INFORMATION•(MUST BE COMPLETED) _ <br /> NAME OF O'N <br /> CAPE OF AODR 7pN <br /> MAILINGORSTREETAODRESS ✓ �nmic>V <br /> Q INOIMAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CITY NAME I Q CORPORATION Q PARTNERSHIP Q COUNTY.AGEWY Q F DEMLAGENCY <br /> STATE LP CODE PHONE s WITH AREA CODE <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 FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Gm ein9pr Q I SELFNSUREO Q 2 GUARANTEE Q 1 NSURMILE <br /> 0 f LETTER OFCREDR 0 a Ex wn w Q a SUR SONO <br /> Q W OTHEA <br /> A. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notiTLLation and billing will be sent to the tank ower unless x 1 or ll IS checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BRL14 <br /> L IL❑ IIL❑ <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,ANO TO THE BEST OF MY KN E.IS TRUE AN FREC7 <br /> APPLICANTS NAME(PP W TED a SIGNATURE) APPLICANTS TITLE <br /> GATE MONTWOAYf/EAR <br /> LOCAL AGENCY USE ONLY 77 <br /> Gam/ <br /> COUNTY s <br /> v JURISDICTION� FACILITY f <br /> & _ <br /> LOCATION CODE -OPTIONAL ICENSUSTRACT• -GPTXMILLISUPVL50R-OLSTRIOTCWE -OPTIONAI- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATK7N• FORM B,UNLESS THIS IS A CHANGE OF SITE WFO TION NLY. <br /> FORM A(5.91) <br /> !/�l�J FORo=A3 <br />