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STATE OF CALIFORNIA - <br /> "STATE WATER RESOURCES CONTROL 30ARDFORM A <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION <br /> V Y/ <br /> y o <br /> - COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY { 1 NEW PERMIT B RENEWAL PERMIT $ CHANGE OF INFORMATION Cj] 7 PERMAN Y E <br /> ONE ITEM 2 INTERIM PERMIT p A AMENDED PERMIT C:1 a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS ` / l� �I I NEAREST CROSS STREET PARCELa(OPIOMU <br /> CITY NAME 5 I / STACA ZIP CODE D I SDE +WIp AA COOE <br /> TO NOICAVE p CORPORAnON p INDUCUAL p PARTNERSHP IJ LOCAL-AGENCY p COUNTY-AGENCY p srAATEAGENcr `O — <br /> p fEOERALAGENCY <br /> DISTRICTS <br /> TIPS OF 3USINESS U 1 GAS STATION ; DISTRIBUTOR p J ;F INDICN <br /> AN +OF TANKS AT SITE E.P.A. L D.+(cbNmA) <br /> D FARM C a PROCESSOR p 5 OTHERESERVAT:R OR TRUST LANDS <br /> EMERGENCY CONTACT PERSCN (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> OAYS: NAME(LASi,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME ILAS T,RPT) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> 04 C+WT4 AREA CQQc <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> VAMPD D CARE OF ADDRESS INFORMAT;CN <br /> M <br /> MAIL.NG OR STREET ADDRESS /J., / J m+b p ;NONIDUAL p LOCAL.AGENCY p STATE-AGENCY <br /> O Vd 6 RPCRATON 'p PMITNERSHP p COUNTYAGI p ;EDERALAG'ENCY <br /> CIT"VANE I STATE I ZIP CODE G I PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) C/ <br /> NAME OF OWNER 5e�hl� at 57 CARE OF ADDRESS INFORMATION <br /> MAIL.NO OR STREET ADDRESS J =bvbEAM p INDIVOUAL p LOCAI.AGFNLY p STATE-AGENCY <br /> p CORPCRATON p PARTNERSHIP p COUNTY-AGENCY p FEDEM.AGENCY <br /> CITY NAME I STATE ZIP CODE PHONE s 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 D Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ �b+WbNA p i SELF:NSURED p 2 GUANANTEE p l INSURANCE p A WAVYBOND <br /> 71 <br /> p S LETTER OF CREW Q S ExEMPr10N p W 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 ch <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLNQ L= IL[]LrIII <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY 10YOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWCAY/YEAA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY IF JURISDICTION a FACILITY a <br /> tb6&p-F✓D6 D <br /> LOCATION DOE -OPTAOML (CENSUS TRACT+ -aP T.ONALSUPVISOR-DISTRICT CORE -OPTIONAL <br /> Z35fo � 3z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION CNLY. <br /> FORM A(&Bl) <br /> Fp100UA5 <br /> i <br />