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STATE OFCALIFORMA '`%O°" " <br /> °i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> ry u <br /> COMPLETE THIS FORM FOR EACMIOCCILITY/SRE <br /> MARK ONLY O i NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY OLO <br /> ONE ITEM ❑ 2 INTERIM PERMIT 0 d AMENDED PERMIT ED S TEMPORARY SITE CLOSURE S� <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> /c <br /> ADDRESS NEARESTCROSS STREET PARCEL A(OFTIONAL) <br /> /v4fo csc� lo. /3 /cD�Ca /2cl Gore�fi G <br /> CITY NAME STATE ZIP CODE DE <br /> BOX SITE PHONE#WITH AREA CO <br /> �SCc�lon CA 9S� ?�j /, 4/7 d,r-7S— <br /> TO INDICATE <br /> S—TOINOICATE O CORPORA INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY (] COUNTY-AGENCY (]STATE-AGENCY O FEOEML-AGENCY <br /> DISTRICTSTYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR O RES✓ IERFVINATION DIAN i OF TANKS AT SITE E.P.A. L D.i(opl/mae <br /> AL 3 FARM Q 6 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST( PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> welc4 Pssr- v7-d ;S,— <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> r"x S� ,X( PHONE#WITH ARF4 COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ,3 P ss e /c f, <br /> CARE OF ADDRESS INFORMATION <br /> c,F'e - <br /> MAILING OR STREET AODRESSp ✓bo WAW Cw IIDU <br /> VAL 0 LOCAL-AGENCY (]STATE-AGENCY <br /> to L7• /.JO K /S2 CORPORATION Q PARTNERSHIP (]COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> s ca !o. ys3Z� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmbhbkm Q INDIVIDUAL (] LOCAL-AGENCY (]STATE-AGENCY <br /> =CORPORATION Q PARTNERSHIP tl COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i 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 - p s a a a <br /> V. PETROLEUM LIST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> J boabbOkaN 1 SELF-INSURED O 2 GUARANTEE Q 3 INSURANCE (]A SURETY BOND <br /> 0 5 LETrEROFCREDT (]S EXEMPTION (]0 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 c ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LO II. 111.0 <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> F31-71 FT 1:'2 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Ob 23� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) -� FORMA-5 <br />