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't9OJ„ <br /> STATE OF CALIFORNIA ' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILiTYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY LOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> C7lC/ZyFIT <br /> ADDRESS NEAREST CROSS STREET PMCEL#(OPTpNAL) <br /> ell 4 ^evil5�v"f ,eo a <br /> CITY NAME STTE ZIP ACODE SITE PHONE M WITH AR D <br /> AZA-,IPO ���,���yyy,,,```` CAv BOX <br /> T NDICATE O CORPORATION INDIVIDUAL = PARTNERSHIP D CAL-AGENCY 0 COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> TRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN MOF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAV : NAME(LAST,FIRS1f PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> /17 o�/ ssf/� lr•� s65-sW/ PHONE 9 WITH AREA r�P <br /> NIGHTS: NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGHT S: NAME(LAS 1,FIRST) PHONE#WITH AREA COOP <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /!Agf3 aN/S,'1-z <br /> MAILING OR STREET ADDRESS <br /> ,� � ✓bax bkxl a f� INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 4n4� ��l/,-�y1 e[yQfL CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAM- E � STATER ZIP CODE �2 ITH A1�RE9_HOE <br /> eAIAr <br /> III.. TANK OWNER INFORMATION-(MUST BE COMPLETED) G/v_ ( 6 <br /> NAME OF OWWNERCARE OF ADDRESS INFORMATION <br /> y' <br /> 160 13 <br /> MAIL 13OORRSSTREET AD�DRREESSS'�� ,p ✓ boa bl,bkale = INDIVIDUAL LOCAL-AGENCY f� STATE-AGENCY <br /> '^ C ( � fj04VA!P 112 a4O �CORPORATION EI PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE P CW0 E WITH lR�DODE�� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. J\'O <br /> TY(TK) HQ 4 4 - c� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box bintlkab O I SELF-INSURED 2 GUARANTEE [=1 3 INSURANCE A SURETY BOND <br /> D 5 LETrEROFCREDIT 6 EXEMPTION O 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.7 II-❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PRINTED&S IGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY C <br /> COUNTY# JURISDICTION• O/V 1.! q19 1� <br /> �' _ <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,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0030A-5 <br />