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i � R�6�Jp C Co <br /> ` STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD e Y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> • C-1 iFOAµyr <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 NEW PERMIT TE] 4 <br /> RENEWAL PERMIT 5 CHANGE OF 4NFORMATION 7 PERMANENTLY CLOSED E <br /> EONE <br /> K ONLY Q <br /> ITEM 2 INTERIM PERMIT AMENDED PERMIT 6 TEMPORARY SITE CLOSU <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAMEOFOPERATC f <br /> DBA OR FACILITY NA E cif[/ [tea/� <br /> CrPARCEL#(OPTIONAL) <br /> ' NEAREST CROSS STREET <br /> ADDRESS <br /> �4 <br /> STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CITY NAME CA Cs 5'' _Z�L' D-00 <br /> h'© - <br /> J <br /> BOXRPORATION f� INDIVIDUAL [�PARTNERSHIP I� LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY � FEDERAL-AGENCY <br /> TO INDICATE i DISTRICTS <br /> a J IF INDIAN #OF TANKS AT SITE ti.P.A. I.D.#(Wionaf) <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RESERVATION / <br /> 3 FARM <br /> 4 PROCESSOR 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 /> Dunmr7 AV <br /> L�q -C CZr"�o E EM:#WIT <br /> �- <br /> NIGHTSME ,: NA (LAS FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRSTS <br /> II. PROPERTY OWNER INFORMATION- ' <br /> MUSTRESS INFORMATION <br /> NAME (� <br /> 1� C te <br /> MAILING OR STREET ADDRESS [� INDIVIDUAL LOCAL-AGENCY [] STATE-AGENCY <br /> D �� Cj ION 0 PARTNERSHIP COUNTY AGENCY (� FEDERAL-AGENCY <br /> if ZIP CODE PHONE#WITH AREA CODECITY NAMESS 2L7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER - CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREETADDRESS ✓ box toindicala 0 INDIVIDUAL Q LOCAL-AGENCY [] STATE-AGENCY <br /> CORPORATION PARTNERSHIP C] COUNTY-AGENCY 0 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) HQ 4 4 -FDTUN3 <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b Indicate I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE [] 4 SURETY BOND <br /> 5 LETTEROFCREDIT 0 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: L= H.= III. <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 S SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# ��A� 7 <br /> [��T F 7_ F1 <br /> LOCATION CODE -_OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNP THIS 4S A CHANGE SITE INFORMATION ONLY. <br /> FORM A(591) ,/ / FOR0033A-5 <br /> ✓ J 11� <br />