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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i '• <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> G o..,. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY t NEW PERMIT3 RENEWAL PERMIT 5 CHANGE OF INFORMATION L-17 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA RFACILITY NAME -y,t NAMEr'OFOPERAT,R n N <br /> AMR `•LJ^ ) N $TC SS STIR /v PMCELII(OPTIONAL) <br /> CITY NA: / STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> �7/rVQY�✓� CA <br /> ✓ Wx <br /> TO INDICATE CORPORATION I�INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY I�STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.x(gNfma# <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR = 5 OTHER pR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE OAVS: NAME(LAST,FIRST) / 7ODE <br /> 'O �a / a <br /> ASOYT (J 1� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME EILAS .FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMEN CARE OF ADDRESS INFORM TION �^ <br /> (A <br /> MAr ORSTREETADDRESS I ✓ Wxbimmme INDIVIDUAL O LOCAL-AG NCV STATE-AGENCY <br /> �CORPORATION 11 PARTNERSHIP =COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE za701 4P y1 PHqNE#WITH AREA CODE <br /> G <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> f <br /> MAILING OR§TREET ADDRESS ✓ boa bbMkm# 0INDIVIDUAL LOCAL-AGENCY E::j STATE-AGENCY <br /> =CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDENALAGENCY <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 - Q Q <br /> V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓boxblMkaN <br /> Ewrl SELF-INSURED (]2 GUARANTEE (] ]INSURANCE 0 A SURETY BDND <br /> I=5 LETTEROFCREDIT 0 6 EXEMPTION D 99 OTHER <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.O II. 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 a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Al FACILITY# 7 <br /> C07 Elemw <br /> LOCATIONCODE -OPTIONAL CENSUSTRACT# -OPHONAL SUPVISOR-DISTRICT CGDE -OPTIONAL <br /> a� <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) FOR0033A,5 <br />