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r. <br /> STATEOFCAUPORMA <br /> STATE WATER RESOURCES CONTROL BOARD s' 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O f NEW PERMIT O 3 RENEWAL PERMIT [?-rCHANGE OF INFORMATION 7 PERMANENTLY CLOSQ SITE <br /> ONE ITEM [�] 2 INTERIM PERMIT F_� 4 AMENDED PERMIT D e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA RFACILITV NAME NAME OF OPERATOR <br /> 0� <br /> ADDRESS NEAREST CROSS STREET PARCEL A(OFT QNAU <br /> CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> 1-ve,ger CA <br /> VAO <br /> BOX <br /> T NMCATE O CORPORATION INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY Q COUNTYAMNCY O STATE AGENCY O FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> IF INDIAN <br /> A OF TANKS AT SITE E.P.A. L D.x(gafiamae <br /> Q 3 FARM Q 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> IIVAIAAI At ul - 0 z <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONEF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ?-VAw"o <br /> MAILING OR STREET ADDRESS ✓bo[bYgicn Q INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> 2 Ol 1a4 -_-�7wor O CORPORATION = PARTNERSHIP 0 COUNtYAGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE HONE N WITH AREA CODE <br /> SAN f xo GA RJ4 2 � Ul5) 92Z-4,z2 <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME OF OWNER 5 /A CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS Immir,&N = INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPDIUTIDN Q PARTNERSHIP 0 COIINTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME 9TATE ZIP CODE PHONE v 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 /> ✓ bN baa, O 1 SELFJNSURED 0 2 GUARANTEE (] 3 INSURANCE Q I SURETY BOND <br /> D 5 LETTEROFCREDIT O I EXEMPTION Q 0 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 c ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PANTED&SIGNATURE) APPLICANTS TITLE DATE MCNTWDAYiYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION It FACILITY• <br /> I I 1/ 16 (3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT& -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> *4 23- GAJ azo 15--r- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS ISA CHANGE OF Sl`TE INFORMATION ONLY. <br /> DORM A(5-91) �/�� FOROMA-5 <br />