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11 <br />0 '�5°URc@.y C <br />STATE OF CALIFORNIA °A <br />STATE WATER RESOURCES CONTROL BOARD o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />o <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY _ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION � 7 PERMANENTLY CLOSED SITE <br />ONE ITEM r 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 01 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA ORfACILITY NAME <br />NAME OF OPERATOR <br />meiizl,3 2_ <br />Qvn S <br />ADD--1�� 4 <br />N STC SS STR ET <br />PARCEL # (OPTIONAL) <br />l.- IIV <br />- <br />�b <br />CI �lA ESTATE <br />CA <br />ZIP CO <br />0q" <br />SITE PH NE # WITH AREA WIDE <br />✓ Box <br />TO INDICATE Lj COR ATION INDIVIDUAL PARTNERSHIP 0 LOCAL -AGENCY Q COUNTY -AGENCY STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTS <br />USINESS 1 GAS STATION a 2 DISTRIBUTOR <br />,/IF INDIAN <br /># OF TANKS T SITE7E.P.A.I. <br />D. # (optional) <br />r!07 <br />RESERVATION <br />3 FARM 4 PROCESSOR 0 5 OTHER <br />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 />PHnNr A WITH AREA G.01117 <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME e co <br />o <br />MA OR STREET DDRESS • <br />� /� O /7 <br />T. <br />CARE OF ADDRESS INFORMATION <br />M 0 STREET DRESS <br />CITf Na <br />ST/Y& ZIO*Z <br />✓ box bindicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />r b <br />�b <br />0 CORPORATION PARTNERSHIP 0 COUNTY -AGENCY FEDERAL -AGENCY <br />CAME <br />ST <br />ZIP ODE PHONE # WITH AREA COD <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAM F WNER p <br />v <br />CARE OF ADDRESS INFORMATION <br />MA OR STREET DDRESS • <br />� /� O /7 <br />T. <br />✓ box to indicate <br />� CORPORATION <br />INDIVIDUAL <br />0 0 LOCAL -AGENCY [� STATE -AGENCY <br />0 PARTNERSHIP � COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITf Na <br />ST/Y& ZIO*Z <br />( 03 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 14 <br />V. <br />C010 0 <br />V. PETROLEUM UST FINANCIX RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate I SELF-INSURED U 2 GUARANTEE [�:] 3 INSURANCE 4 SURETY BOND <br />5 LETTER OF CREDIT 0 6 EXEMPTION CJ 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 ' checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 11.1/1 III. 17 <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 & SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY # L4KL_F_r_JURISDICTION # FACILITY # <br />39heosol �..G3 <br />_OC,ATiON COD /OPTIONAL CENSUS TR/�'.T # - OP J,� SUPVI DIS RICT CODE -OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MC/O/R/E PERMIT APPLICATION - FOGR9iM B. UNLESS THIS IS A CHANGE OF SITE INFORMATI N ONI Y <br />FORM A (12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS,,/' <br />FOR0033A-R6 <br />7 <br />