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a <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH F Y/SITE <br /> MARK ONLY Q I NEW PERMIT 3 RENEWAL PERMIT CHANGE OF INFORMATION E T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 1r3 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ` NAME OF OPEpgATOR <br /> ADDRESS NEAREST CROSS STREET PARCELA(OFTONAL) <br /> 03 GiA=�t� <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> CA <br /> I/ 80% <br /> TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q ODUNTYAGENCY <br /> DISTRICTS QSTATE-AGENCY Q FE#RAL#GENCY <br /> TYPE OF BUSINESS Q 1 GAS STATION E::] 2 TOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. L D.i(EPIAXwU <br /> 0 3 FARM [:jK44 PROCESSOR 5 OTHER Q RESERVATION <br /> Q OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> rPPr SB ar v 9 —d' 3d 3543 <br /> NIGHTS: NAME(LAST.FIRST) PHONES WITH AREA CODE NIGHTS: NAME(LAST.FIRST) IIH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME p p /, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓bE�b' Q INDIVIDUALQLOCAL-AGENCY QAG <br /> STATE- ENCY <br /> I✓�I 7�iA-sem Sf — flPORATK)N Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> ,ES'CGr lv�h (2 9532 (� Z09 -8 3A - sem? <br /> III. TANK OWNER INFORMATION• (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS -- _ Eat 0mdiO Q INDNIDUAL Q LOCALAGENCY Q STATE- <br /> AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNry#GENCY Q FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A 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 - j 2 <br /> V. PETROLEUM UST FINANCIA ESPONSISILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ OM bYtBeL� I SELF-INSURED IQ 2 GUARANTEE Q 7 INSURANCE <br /> Q 5 LETTER OF CREDIT Q t SURETY BOND <br /> Q B EXEMPTION Q 93 OTHER <br /> A. 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.O 11. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY 10VOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TIRE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY K JURISDICTION k FACILITY A <br /> 37 a Y <br /> LOCATION CODE -OPnONAL CENSUS TRACT8 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> °V 3 DISTRICT <br /> G <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> (�\ FORMA-5 1 L <br />