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STATE OF CALIFORNIA c e <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FA (SITE <br /> MARK ONLY 1 NEW PERMIT F73 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMAN LOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT [__1 q AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) IF <br /> DBA OR FACILIT/CE NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME `` STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> SAO c.F4;- �SZIJ CA (. y, <br /> ✓ Box _ <br /> TO INDICATE D CORPORATION O INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY [=1 STATE-AGENCY E__] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTORO ✓ IATION <br /> FVINDIAN #OF TANKS AT SITE E.P.A. I.D.#Iapth"I) <br /> 3 FARM RESER <br /> O 0 PROCESSOR ER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LA T,FIRS[ PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> - ?7 -�104 ra U 0 1 �— <br /> NIGHTS: NA (LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> S yd PHONP 4 WITH AREA CODE <br /> n s 2pll'` o91f3Fo <br /> II. PROPERTY OVftiER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> u YiLA1 �s <br /> MAILING OR STREET ADDRESS ✓ bw bintlkau F1 INDIVIDUAL 0 LOCAL-AGENCY STATEAGENCY <br /> CORPORATION [_�] PARTNERSHIP 0 COUNTYAGENCY Q FEDEML-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Sa •�-� 4 s <br /> MAILING OR STREET ADDRESS ✓ box bindicaN INDIVIDUAL O LOCAL-AGENCY ED STATE-AGENCY <br /> M CORPORATION 0 PARTNERSHIP [7:1 COUNTY AGENCY [::] FEDERAL-AGENCY <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 F4 31-2-17, <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Ear binEkm (]1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE E=j A SURETY BOND <br /> D 5 LETTEROFCREDIT [7:16 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I Checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O III.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 /> LOCATION CODE -IP770NAL CENSUS TRACT##-OpTp VAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> V ? OY7o\ ffV 7r/3/5 2- <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 Is 91) <br /> % FOiiW73A.5 <br /> V `� <br />