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yyaJa � <br /> Y y y� <br /> STATE OF CALIFORNIA g <br /> STATE WATER RESOURCES CONTROL BOARD o� - ';a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 5� �a e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> DBA��F ` f` r'FSell <br /> NEAREST CROSS STREET PARCELa(OPrgTUU <br /> ADpl+13 Bourbon Stree' <br /> STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> 01Mo9ckton CA 2 4 <br /> TO,/ BOX <br /> TE CORPORATION 0 INDIVNIUAL O PARTNERSHIP Fj DISTRICTS' <br /> LOCAL-AGENCY �COUNTY�AGENCY' 0 STAT6AGENCY' I� FEDEIUL#GENCY' <br /> If owner elraffleLIST Is a public agency,mMurre the following:raffle of Supervisor of d"Ion,section,or office which bible w the UST <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN a OFT lrw, AT SITE E.P.A. I.D.a(gNblag <br /> ❑ RESERVATION <br /> ❑ 3 FARM ❑ A PROCESSOR E:j 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONEOWITHAREACODE DAYS:NAME(LAS'.FIRST) PHONE a WITH AREA CODE <br /> Dac ;TFgST)ll Emergency Control 510 -NIGHTS: NAMET.FIRST) <br /> PHONE a VATHAREA CODE NIGHTS: NAME(LAST.FIRSTt PHONE 0 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME cific Bell L � <br /> T`GswuT L)L <br /> qE S���� ��;.��/� ✓lm bb9caa 0 INDIVIDUAL LOCAL-AGENCY SlATEAGENCV <br /> �_US!RANl41n , '�6A�m Ij;9 T'+ <br /> CORPORATION E3 PARTNERSHIP O CWMYAGENCY O FEDEPAI AGENCY <br /> CLQ NAME <br /> vG. STATE ZIP CODE PHONEa WITH AREA CODE <br /> YAR–�iD.0�1 �C,C�Or`\c�-1?p SUt�c <br /> III. TANK OWNER INFORMATION- UST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> "'PQG L �" VROMU ENCY STATE-AGENCY <br /> MAjUh4 OR STREET ADDRESS ✓ Em bYdkya INDI <br /> (,.. ( �..CC-.\ l t`"Il 1 C_ .'1'h 3 CORPORATION O PARTNERSHIP 0 COUNTY�AGENCY 0 FEDERALAGENCY <br /> CRY NAME STATE ZIP CODE PHONE a WITH AREA DOM <br /> CA w <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it quesfions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓OeX bYdk9Y D f SELF-INSURED O 2 GUARANTEE D INSURANCE D A SURETY BOND <br /> D 5 LETTER OF CREDIT O 6 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 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ I. Ill.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> DATE MONTHIDAYNFAR <br /> OWNER'S NAME(PRINTED&SIGNED) <br /> OWNER'S TITLE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION L_J-1J N FACILITY <br /> Il I��I- ISI I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL 9UPVISOR-DISTRICT CODE -OPTIONAL <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOP4"417 <br /> FORM A(393) ` ( �/ I ✓�I-�-/, <br />