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4lOUR ! <br /> STATE OF CALIFORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD i ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A w mom, v <br /> . . o <br /> COMPLETE THIS FORM FORE H FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT F-� 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE 53 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> F6- Co <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> So <br /> CITY NAME STATE ZIP pDE / SITE PHONE#WITH AREA CODE <br /> CA YY 10 <br /> X CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDEMLAGENCY <br /> TOINdOCTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR = <br /> RESERVATION <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#laplim#I) <br /> 3 FARM Q 4 PROCESSOR = 5 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 /> Alu / OW 2oq-277 -3SY� PHONE 9 WITH AREA COnF <br /> NIGHT AME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> M 6- 6> <br /> MAILING OR STREET ADDRESS V bmOlMiege O INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> o_ Sob CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY E�l FEDERAL-AGENCY <br /> CITY NA E STATE ZIP CODE PHONE#WITH AREA CODE <br /> zle,Av 0C�9 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> q-r --z- <br /> MAILING <br /> MAILING OR STREET ADDRESS ✓box blMmaD D INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION E::] PARTNERSHIP O COUNTY-AGENCY l= FEDERALASENCY <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 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ boxbindwab [7 1 SELF-INSURED Q 2 GUARANTEE l= 3 INSURANCE E-]4 SURETYBOND <br /> D 5 LETTEROFCREDIT EXEMPTION E=I 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notilication 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 it.eH.O <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Ifb Ir. RAMS so <br /> LOCATK)NCODE -OPPONAL CENSUSTRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2-3.90 1 3zs e c <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 /> FORMA(5-91) FOR O'3A5 <br />