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�ssooa - o0 <br /> STATE OF CALIFORNIA s <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD s' ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION L_] 7 PERMANENTLYC D ITE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR ,A,, 6 <br /> ADDRESS 60 Q ✓'C NEAREST CROSS STR ET PARCEL I(OPTIONAL) <br /> CITY NAM STATE ZIP CODE S PHONE#WITH AREA CODE <br /> v BOX c � n CA 5 32v 9 <br /> TO INDICATE (]CORPORATION Feo DIVIDUAL O PARTNERSHIP L�j D CAL-AGENCY O COUNTYAGENCY D STATE-AGENCY E-3FEDERAL-AGENCY <br /> TRICTS <br /> TYPE OF BUSINESS E�GAS STATION 2 DISTRIBUTOR E7 IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(RINlanae <br /> RESERVATION <br /> Q 3 FARM O 4 PROCESSOR Q 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,FIRS Y 3 Y'3 Z <br /> Ova 3-L Ilei <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME( AST,FIRS 3 Si 2 6 3 G <br /> F36r .7 y / / <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bolbIndleMe INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 13 Lepl INCORPORATION 0 PARTNERSHIP O COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME �eSTATFy ZIP CODE PHONE#WITH AREA CODE <br /> -5 L2 4q S3 -S.3- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDREITS bo,cb1m.* INDIVIDUAL O LOCAL-AGENCY [=1 STATE AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#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�-It12�/I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm 0md"te E:::] 1 SELF-INSURED E:j 2 GUARANTEE Ell 3 INSURANCE O 4 SUREtt BOND <br /> = 5 LEn EROFCREDIT [=]6 EXEMPTION = W OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is ch <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L[-] II. III. <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 B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNT # IA <br /> JURISDICTION FACILITY VLQDI.J I� <br /> �1 <br /> LOCATIONCODE -OPTIONAL (CENSUS TR,L'sT# -OPTIO L � ISUPVISOR-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 /> FORM A(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE <br /> /TANK REGULATIONS <br /> C��'��/✓' FOf10013AA6 <br />