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STATEOFCAUFORMA a <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> C —>� COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLYD SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> i�Gi PelT crr1P <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> / / S <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> G oAr)Z CA <br /> TOINDICATE 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY COUNTY AGENCY E] STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(opAml) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR E;��OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) 1 EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE j DAYS: NAME(LAST,FIRST) <br /> /� ZL_ A/W 'rJiPHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 4� GGi.4'" G46z)K," <br /> MAQ EE5RE0Irtk � INDIVIDUAL O LOCAL-AGENCY I�STATE-AGENCYSS G <br /> D CORPORATION 0 PARTNERSHIP COUNTY-AGEICY O FEDERAL-AGENCY <br /> CITY NAME 0� STAT ZIP CODE ^ H WITH AREA CIHIE <br /> _—/FJ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 114,At G acr/ <br /> MAILINGOR REET ADDRESS ✓W.thkau I= INDIVIDUAL 0 LOCAL-AGENCY Q SrATE.AGENCY <br /> 6 � /, CORPORATION = PARTNERSHIP 0 couNTYAGENCY =1 FEDERALAGENCY <br /> CITY WE STATE j ZIP CODE HONE#VQTHA EA CODE <br /> TUGS%v/L G/a qh Zr7 q16 -moi(2 <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO F41 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> but Wmaa 1 SELF-INSURED [::]2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTEROFCREDIT =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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O III.0 <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 B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION# FACILITY x <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL e� <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) Fg16073 <br /> 12i /A> 5 <br />