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��eo�F e <br /> STATE OF CALIFORNIA ^� �� <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A m� u s <br /> � , a <br /> �FOFM�F <br /> 14 COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY Q T NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOr D SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O a TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAMEOFOPERATOR <br /> d //4�v/e��wo <br /> ADDRESS � � NEAREST CROSS STREET PARCEL eIOPrONAy <br /> CITY NAME STATE ZIP CQpE�� SITE PHONE M WITH AREA CODE <br /> OT'> CA <br /> T 1NgICAT <br /> 0E D CORPORATION I)(INDIVIDUAL Q PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY D FEDERAL-AGENCY <br /> T DISTRICTS <br /> TYPE OF BUSINESS ) GAS STATION Q 2 DISTRIBUTOR RESERVAOTION A OF TANKS AT SITE E.P.A. L D.8(OPIiMaI) <br /> Q 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 R WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> A C!i/GGT -9PHONE&WITH AREA rnnF <br /> NIGHTS: NAME(LAST,FIRST) PHONE e WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PWQNI`8 WITH AREA <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ` A CARE OF ADDRESS INFORMATION <br /> MAILING OR SOT ADW;:,, 4J' .1 b..I)WW42 <br /> DNIDUAL O LOCAL-AGENCY =1 STATE-AGENCY <br /> P <br /> CORPORATION Ej PARTNERSHIP O COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAM STA ZIP CODE!N PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /o�jb v O loge UAp2(_ <br /> MAIL( OR STREET ADDRESS J ✓Doz 0MdNNe NDIVIDUAL D LOCAL-AGENCY O STATE AGENCY <br /> ®1 /�� /gZ l�CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE A ZIP COD.F. PHONE#WITH AREA CODE <br /> 7-old li <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ two picgicale O 1 SELF-INSURED O 2 GUARANTEE 3 INSURANCE 4 SURETY BONG <br /> D 5 LETTEROFCREDR Q 6 EXEMPTION W 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.= 111.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY n JURISDICTION p <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> o Z 3 <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) F 33A�5 <br />