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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> L�ERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> r-' <br /> COMPLETETHIS FORM FOR EAC ACILITYSRE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ^ 5 CHANGE OF INFORMATION T P'eRMANENT OSEO BITE <br /> ONE REM J 2 INTERIM PERMIT O 4 AMENDED PERMIT J 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO-FACILITY NAI // NAME OF OPERATOR <br /> L�s�V ✓Gt-,^ <br /> ADDRESS / � NEAREST CROSS STREET I PARCELA(ORgMAI) <br /> p/ <br /> CITY NAME ATE ZIP <br /> CODE SITE PHONE 9 WITH AREA CODE <br /> TO OBO hh p DORPORATION p mvouAML p PMTNERBRIP ED=�CY ED COUNTY-AGENCY ED STATE-AGENCY CD FEDEM AMI CY <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br /> .1 IF INDIAN s OF TANKS AT BITE E.P.A l D.•(opIKYW) <br /> Q � � RESERVATION <br /> O 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> P [s NTH ARcA <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ w bw1caw p MWOUAL p =ALAWICY p STATE-AGENCY <br /> p CORPORATION p PARTNERSIOP p cOUNrYAGENCT' p PEDEML AGENCY <br /> CITY NAME I STATE I ZIP CODE PHONE 6 WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Ow N/i0/JN p NONOUAL p WM AGEPKY ED STATE-AGENCY <br /> p CORPORATION C PARTMERSNP p COMWTYAGENDY p FENTEMLAGENCY <br /> CITY NAME STATE I LP CODE PHONE P WITH AREA CODE <br /> IV.BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 If questions arise. <br /> TY(TK) HO F474 - <br /> 0 3 d <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ P�4icM1 p 1 SELF-INSURED p 2 GUARANTEE p 3 INSURANCE p A SURETY BOND <br /> p 5 LETTEROFCAEOIT p f EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or MI's checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND WLLNG: L R. MIL <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(PRNTED A SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION L_L_.L17/ FACILITY GyFUR O� <br /> �L_Jl—ALL/_lL�13ISI <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT r�T� I SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Q,0 /—d7 T13 <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) FOR=3A 5 <br />