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" es <br /> STATE OF CALIFORNIA ^P'� oo `�i <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "m� �; <br /> . , a <br /> `�t,eO�N,� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT [_—] a AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OF OPERATOR �a <br /> M i C v/..I/9. /t <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> z . N >GE ipy <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 141,4/ CA 5334 <br /> BOX <br /> TOINDICATE F-1 CORPORATION [—I INDIVIDUAL [__3 PARTNERSHIP O LOCAL-AGENCY Q COUKTY-AGENCY STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optbnal) <br /> 3 FARM A PROCESSOR 5 OTHER RESERVATION <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(( ST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRan <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S..L � Co. <br /> MAILING OR STREET ADDRESS -� ✓hor bhNbaU INDIVIDUAL 0LOCAL-AGENCY <br /> Ent'SfATE-AGENCY <br /> S) S( 16q C_i �`,L O CORPORATION O PARTNERSHIP ED COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S'+e�r_ 01 1 (07-07 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ bor 0iMkam INDIVIDUAL ED LOCAL-AGENCY (]STATE AGENCY <br /> CORPORATION O PARTNERSHIP =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) HO L4 4 -I —_L..--I� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Eox min4kale O I SELF INSURED 2 GUARANTEE D 3 INSURANCE (]A SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION m 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.0 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 /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# SA�/Jp S <br /> LOCATIONCODE OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 326 z-3 2--3 /Z—S3 :F'� <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(12 e1) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK R IONS <br /> FOM033A R6 <br />