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I �DUR f <br /> ' STATE OF CALIFORNIA s <br /> STATE WATER RESOURCES CONTROL BOARD ; 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> s.� . o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT U 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARe o <br /> ADDRESS/� G � A w��/ NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> C, /`7,�-ego' " P+ of^/Tele <br /> CITY NAME STATE ZIP CODE SI PHO a WITH AREA CODE <br /> _f7 0Ck7� CA `�SZo (?�4 4(o&- 9,!;' <br /> BOX <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS / IF INDIAN if OF TANKS AT SITE E.P.A. I.D.s(optimal) <br /> RESERVATION <br /> CI 3 FARM J a PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) J PH NE a WITH AREA CODE DAYS: NAME(LAST,FIRST) 6' /j&&_ 95 <br /> ,r�,d#C4.4�a,/ (l.�7 (e M,fMaaE1z a,/ G� ( T <br /> WITH AREA rnnc <br /> NIGHTS: NAM (LAST,FIRST) NON a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) G 77— 63r49 <br /> A7/1.jfi,4EQ OV 417-1 Z �& - 75110 i4.�eC7/�!'ia/N?c�/R�v(�CIITH -/ <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME `2L'o ��/0 T�^/ �' CARE OF ADDRESS INFORMATION <br /> E Y At S <br /> MAILING OR STREET ADDRESS ✓ box toindem 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> /30X &D3v T11ORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ! STATE_ ZIP CODE P.P NE a WITH AREA CODE <br /> 0707- &0.3!8 C-70- <br /> 111. <br /> -70-III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF e,0 n C 75 CARE OF ADDRESS FORMATION <br /> MAILING OR STREET AD RES'S` /�/ ✓ box to indicate � INDIVIDUAL 0 LOCAL-AGENCY � STATE-AGENCY <br /> v Eox 60 (CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAMES;T�TF„ ZIP CODE P NE a WITH AREA CODE <br /> !-�2 T£5✓,4 L r- 670 o © -(cb ? 670- 5¢0 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 1-i,()10 1015[0 <br /> V. PETROLEUM UST FINANCIAL,RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box io indicate -PI1 SELF-INSURED 2 GUARANTEE 3 INSURANCE �_ 4 SURETY BOND <br /> 5 LETTEROFCREDIT ! f 6 EXEMPTION 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.= II.= 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 8 SIGNATU ) ; APPLICANTS TITLE DATE ONTHUDAYNEAR <br /> iiiiiII&I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -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) FOR0033A-5 <br />