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� J <br /> eou» <br /> STATE OF CAUfORMA "os <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> i e YI o' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ^Y <br /> I MARK ONLY ❑ ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTL D SRF- <br /> ONE REM ��,, 2 tNTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE of <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME ( 14- A' NAMEOV PERATOR yy��,,., I/�V, <br /> ADDRESS ( me N Q� LL <br /> �G NEAReSI 13 <br /> -T- 3STR ET t Ai10ELA(OPrIONAy J <br /> CITY NAM STATE ZIP CODE y�f <br /> SC. PHONEa WITH AREA CODE O0 <br /> v Box <br /> �/ CA <br /> TO INDICATE O CORPORATION 92]` MUAL 0 PARTNERSIAP 0 DISTRICTS 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERALAGENCY <br /> TYPE OF BUSINESS C TGAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN s OF TANKS AT SITE E. (Ppriuyl) <br /> Q 3 FARM O4 PROCESSOR 5 OTHER a RESERVATION P.A. I.D.a <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AgFA CODE GAYS: NAME(LAST,FIRS <br /> 57"77Y 3532 <br /> NIGHTS: NAME(LAST,FIR$ le- <br /> PHONE a WITH AREA CODE NIGHT$: NAME(EMT,FIRS <br /> sr36- --7y / / 1 9�336 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> v 1 n VVI o�C.�( <br /> MAILING OR STREET ADDRESS ✓ hoAuillA"raN O INDIVIDUAL <br /> 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> elfsccrl 10,9-CITY NAME D CORPORATION0 PAATNER$yp 0 COUNTYAGENCY 0 FEOEML#GENCY <br /> STATE ZIP CODE PHONE a WITH AREA CODE <br /> G '' S3 c�::) _3s3L <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> [NAME OF OWNER <br /> ILING OR STREET ADDR 0 OCAL-AGENCY 0 STATE AGENCYY NAME' - =1 CORPORATION 0 PARTNERSHP =COUNTY-AGENCY ED FEDERAL <br /> STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Eor aiMicme 0 I SELF-INSURED 0 2 GUARANTEE (] ]INSURANCE <br /> O 5 LETTER OF CREDIT 0 8 EXEMPTION 0/SURETY BOND <br /> 0 W 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 <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.❑ 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 a SIGNgTURE) APPLICANTS TITLE <br /> DATE MONTWDAY/VEAq <br /> wCnc AGENCY USE VIVLT <br /> COUNTYx JURISDICTION# FACILITY R V L (� <br /> LOCATIONCODE OPTK)NALGENSUS TRgCJi -Op TAO L SUP-VISOR CODE -OPTIONAL <br /> C:=> e7- <br /> THIS <br /> 'g <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 1 OR MORE PERMIT APPLICATION• v <br /> PORIA A(12-sn FILE THIS FORM WITH THE OAL AGENCY IMPLEMENTING THE UNDERGROUND STOPTMIS-ANK REGULATIONS SITE INFORMATION ONLY. <br /> �� <br /> �� '`j fOg00IOAA6 <br />