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V � sewn e <br /> STATE OF CALIFORNIA o`s� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY Q 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CL <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE 4/ <br /> 1. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> Ol♦ PA10i aa, 1 61 J'lwtco rvck -&7,q i"a.-� v as <br /> ADDRESSNEAREST C[`�Og1SS_TREET PARCEL#(OPTIONAL) <br /> I (9 2-Z '/®A 0.C lC TU/I G <br /> CITY NAME//� STATE ZIP CODE S PH E#WITH AREA CODE <br /> K2 on ca 453G� Zo5 S`t9- z1IZ <br /> ✓ <br /> BOX <br /> TO INDICATE CORPORATION D INDIVIDUAL D PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY O FEDEML#GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS S STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L O.#(opfi T l) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR Q 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: (LAST,FIRST) <br /> V YLCGa1 I i rg%wt 2057 !Sqq - 211L <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> S 9 7-713 <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ) tI I O CARE OF ADDRESOG�ION 4 • C <br /> AD R <br /> MAILING OR TR TEGq S ✓ boa b Indicate 0 INDIVIDUAL O LOCAL-AGENCY [-1 STATE-AGENCY <br /> Ip D [ (e— Ic- O CORPORATION D PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE ONE#WITH AREA CODE <br /> cQ 9�/©�� 11S -761- 2-7—v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> A S <br /> MAILING OR STREET ADDRESS ✓ box blrbkW INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY O 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 4 4 02 y -/ 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa b indicate 1 SELF INSURED 0 2 GUARANTEE 3 INSURANCE (]4 SURETY BOND <br /> D 5 LETTER OF CREDIT O&EXEMPTION 99 OTHER <br /> 771 <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.= II. 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(PR INTED&S IGNATURE) APPLICANTS TITLE DATE MONTWDAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# T�FACILITY# 3(m[t7 ZZ <br /> ffil ET-E] <br /> L---LVZ-1-=-L-U <br /> LOCATION CODE -OPTIONAL CENSU3TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OP710NAL <br /> 23 k-5Z 6 - D- 9 Z <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(&91) �,(//fOR9933� <br />