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%mmv� V 6 Uw E <br /> STATE OF CALIFORNIA ,� �*� <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> ' UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> v/ ve <br /> r.. o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY OSED SITE <br /> ONE ITEMLp 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NPP E NAME OF OPERATOR <br /> 86372 'T�w. e-%e rJ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> S-75- W. • •} �iYnt <br /> CITY NAME STATE I ZIP CODEDSTTE PHONE#WITH AREA COE <br /> %f-C' CA R53't a-*9 - 1936 - 12-3I/ Box3 <br /> TOINMCATE O AORPORATION 1]SJ INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNrY-AGENCY 0 STATE-AGENCY L=j FEDERAL#GENCY <br /> l DISTRICTS <br /> TYPE OF BUSINESSI� 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal/ <br /> 'fi RESERVATION I u <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS L 000 7.-t G v` 6 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) .90q - B 3 6- 17-33 <br /> 2SerJ TO.W2S aO — 636-17,33 rnnF <br /> NGTS: NAME( TIR� PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) - 835— lY o 5- <br /> � �i <br /> ts¢xJ ¢se.AA DE <br /> H. PROPER Y OWNER INFORMATION• MUST BE COMPLETED <br /> NAME . — CARE OF ADDRESS INFORMATION <br /> �1 a iG��" ^� <br /> MAILING OR STREEIr ADDRESS ✓ boxblMbala [INDIVIDUAL (] LOCAL-AGENCY O STATE-AGENCY <br /> 0. U `zEY7 0 CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ra ctl FK I T537 (o <br /> III. TANK OWNER INF RMATION-(MUST BE COMPLETED) <br /> NAME OF_QIV NERr ' A ( + CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD RESS ✓ Eox blMkab INOIVIOUAL LOCAL-AGENCY E-1STATE-AGENCY <br /> •D- Soo CORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIPCO ���y P�(b WIT�Y2H AREA CODE ^�OO <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 METHODS) USED <br /> ✓ box tlm;b M1 5 SELF-INSURED =2 GUARANTEE l� 3 INSURANCE 0 4 SURETYBOND <br /> LETTER OF CREDIT =6 EXEMPTION W OT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing w' s o t owner unlessb I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS D BILLING: I. II. III. <br /> TH/S FORM HAS BEEN COMP TED UNDER PE Y OF RJURY,AND TO THE B KNOW E,IS E AND CORRECT <br /> APPLICANTS NAME(PRINTED SIGNtTORE) APPLICANTS TI LE DATE MONTHDAYNEAR <br /> V ra_ � 1 a, I�sf. 1 Z -1 - 52, <br /> LOCAL AGENCY USE ONLY p <br /> COUNTY# JURISDICTION# FACILITY# j <br /> Ctie✓�-S � 0 0 �.� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTR T CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(5-91) F <br />