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a <br /> .�...qy <br /> STATE OFCALIFOR14A <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> yi . <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT jZ5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT C:] e TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> o a <br /> ADDRESS �- <br /> NEAREST CROPS STREET PARCEL X(OPrgNAU <br /> pep VV/NN Lam". <br /> CITU NAME STACA 21Q UPTE NE#WITH AREA2CODE <br /> Aon7 <br /> +- <br /> TOINp�ATE ED CORPORATION INDIVIDUAL 0 PARTNERSHIP [:D LOCAL-AGENCY E:1 COUNTY-AGENCY it STATE-AGENCY E:1 FEDERALAGENCY <br /> DISTWCTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORi gESERVATIAN #OF TANKS AT SITE E.R A. L D.#(op#ana) <br /> ❑ 3 FARM ❑ 6 PROCESSOR 5 OTHER OR TRUST LANDS O <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST( PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �IC� / 3 <br /> NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> wavos �gJ 368- s�/1� PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ''57 _ G E G[aeP . <br /> MAILING OR STREET ADDRESSQ INDIVIDUAL (] LOCAL-AGENCY Q STATE AGENCY <br /> '7,9z) _ 57 ✓ COPPoMTION O PARTNERSHIP (]COUNTY-AGENCY 0 FEDERAL#GENCY <br /> CI jjAyE ! � 3TgV�ATE DOEZI ��O PHOT ITHAREACODE <br /> A CO�/ <br /> III. TANK OWNER INFORMATION_(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> O <br /> MAILING OR STREET ADDRESS ✓ Wt kw Q INDIVIDUAL Q LOCAL-AGENCY ED STATE-AGENCY <br /> 7O 5�7'/4�� r ORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> O <br /> CITY NAME STATE ZIP CODE <br /> XA HNE-�t`� Av r y3Ifo pfv�ITH ARr C-090I/ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-95t5 if questions arise. <br /> TY(TK) HQ 4 T- <br /> V. <br /> 2 Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Ooa binOkaU O 1 SELF-INSURED [::12 GUARANTEE 0 INSURANCE O X SURETY BOND <br /> O 5 LETTER OF CREDIT I=S EXEMPTION V999 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.❑ 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&SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FSK ® rl+5LP s6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONALSUPV,IaSOR�-DISTRICT CODE -OPTIONAL C•� ' � \ <br /> U Z— • aV !/V L <br /> THIS FORM MUST BE ACCOMPANIED LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORMAS 1 <br />