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STATE OF CALIFORNIA of <br /> STATE WATER RESOURCES CONTROL BOARD iy 'o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w�� ua <br /> COMPLETE THIS FORM FOR EACH F Y/SITE <br /> MARK ONLY � 1 NEW PERMIT O 3 RENEWAL PERMIT [?-5—CHANGE OF INFORMATION 7 PERMANENTLY O RE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR ' / <br /> OG fJtr J C K 4'I'/t1 vA, iCo— <br /> ADDRESS '' 11 NEAREST CROSS STREET PARCEL#(OPTi8N_ <br /> Zb W �. I. OG ✓.ST <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> moo, CA <br /> v BOX <br /> N ^5366 <br /> T INDICATE 125 PORATION INDIVIDUAL �PARTNERSHIP LOCAL �COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ,/ IF INDIAN #OF TANV�T SITE E.P.A. .D.#(optiplal) <br /> RESERVATION <br /> Q 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME 1 CARE OF ADDRESS INFORMATION <br /> MAILING ORS EETADR SSD ✓ ba bNbkab 0 INDNIDUAL LOCALAGFNCY STATE-AGENCY <br /> C9 (•.JG S =CORPORATION = PARTNERSHIP 0 COUNTYAGENCY Q FEDERALAGENCY <br /> CITU NAME O ^ STATSZIP CCIDE / PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box IoNdule INDIVIDUAL I=LOCAL-AGENCY STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4]-4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ba bintlkaN 1 SELF-INSURED =12 GUARANTEE 0 3 INSURANCE Q /SURETY BONG <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION 0 99 OTHER <br /> 71 <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: I.D I Tn <br /> III.❑ <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&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# '0g6025p' 20 <br /> r, 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FORW17� <br /> �1 �CJ <br />