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• 0 oun <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C PLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q f <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OFOPE ATOR <br /> P2 �� AQ7— �o Y GJlfo <br /> ADDRESS / NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> J S7 - <br /> CITV NAME <br /> STATE Zip CODE ITE P NE#WITH AREAFOD <br /> UBOX/isi�• 9 z 3 72 7-671 <br /> TOINDICATE CORPORATION [:J INDIVIDUAL Q PARTNERSHIP 0 LOCAL-AGENCY O COUNTYAGENCY STATE-AGENCY E-1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAG STATION 2 DISTRIBUTOR O ./ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(CPllanaq <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS' AME(LAST.FIRST) HONE#WITH 85EA CODE DAYS: NAME(LAST,FIRST) <br /> zm <br /> f <br /> s<< � <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA DE NIGHTS: NAME(LAST,FIRST) <br /> 2 -)76 - <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATIp��� �� <br /> MAI NNo OR STREET ADDRESS ✓ Dox biMbati, O INDIVIDUAL El LOCAL-AGENCY Q STATE-AGENCY <br /> RPORATION 0 PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITU NAME � i ATE ZIP CODE/ -2/f pONE�LWITH AREA je <br /> ���Db <br /> III. TANK OWNElR/INFORMATION-(MUST BE COMPLETED) 7 Jl <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> tel' v�-G Go <br /> MAILJI�I✓G OR STREET`ADDDRES ✓ box bindicale l� INDIVIDUAL 0 LOCAL-AGENCY [� STATE AGENCY <br /> / 'GEU� h& �'' CORPORATION O PARTNERSHIP = COO�U�NTTYAGEE)rNCCYp FEDERAL AGENCY <br /> CITU NA G�/Q ZIP CODE / ACODE <br /> -JITI�Q Er_ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4 44]-lc�lJ L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Loxloilkala [] I SELFINSURED 11 2 GUARANTEE 0 3INSURANCE E-]4 SURETYBOND <br /> I-J 5 LETrEROFCREDIT E-1 6 EXEMPTION = IN 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN16 CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANPS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> _ TIO N - <br /> IOGATIONCODE -OPTIONAL GE�US..RVT 11 -OPTIONAL SUP OSOR-OISTRICTCODE -OPTIONAL /F7735/9 <br /> THI FORM MUST BE ACCOMPANIED BY <br /> ATC LLLEE7IASSTT(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGEOF SITE INFORMATION ONLY. <br /> FORM A(12-e1) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 6 . ^n�;e FOR0033A R6 <br />