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zouw <br /> STATE OFCALIFORNllA `� P `°,� <br /> STATE WATER RESOURCES CONTROL BOARD _ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W�� ve <br /> C �4�non M`n•o <br /> COMPLETE THIS FORM FORE H FACILRYfSITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT [_] 4 AMENDED PERMIT & TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMEn ��LL�� NAMEOFOPERATOR <br /> L-ON�7/L( DN 4 n/ <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> N <br /> CITY NAME STATEZIPCODE SITE PHONE#WITH AREA CODE <br /> Fri C4 CA 9 <br /> ✓ BOX <br /> TOINDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY 0 STATE-AGENCY 0 FEDEMLAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.x(optimal) <br /> RESERVATION <br /> Q 3 FARM 4 PROCESSOR Z5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> N Eo! ..209 - - n o <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR / box b Idbale = INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> D k =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> /W-JQ ` 6v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER /� �-L CARE OF ADDRESS INFORMATION <br /> AN-& G�sa �I0 _ <br /> MAILING OR STREET ADDRESS ✓ bw bindicate INDIVIDUAL O LOCAL-AGENCY E-1 STATE-AGENCY <br /> 0,500 S• N D CORPORATION E=l PARTNERSHIP O COUNTY-AGENCY E71 FEDEMLAGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> G9 �a <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 44 -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bUbindbaN I SELF-INSURED 0 2 GUARANTEE lD 3 INSURANCE 4 SUREtt BONG <br /> 5 LETTEROFCREDn O&EXEMPTION O 99 OTHER <br /> 771 <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.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> GRANrya <br /> LOCATION COD -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 23.90 1 3 2.s 3 cif <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(6-91) FOR0033A-5 <br /> Li 45 <br />