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-uYG^'^« •^n�renwuawrt.sn. � LLOUM t <br /> STATE OF CALIFORNIA >; <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA `< o <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT E:��CHANGE OF INFORMATION E] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT E 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> DSA OR FACILITY NAM T VA✓I C-5 <br /> PADDRESS _ e aA. NEAREST CROSS STREET PARCELR(OPrpNAL) <br /> STEWITH AREA CODE <br /> 95 33rd zBOXPoRATON O INDIVIDUAL 0 PARTNERSHIP Q L CALL-AGENCY En—COUNTy.AGENCY O STATE-AGENCY (] FEDEPAL-AGENCY <br /> ISTRICTS <br /> GAS STATION 2 DISTRIBUTOR OIF INDIAN %OF TANKS AT SITE E.P.A. I.D.%(ap!analf <br /> RESERVATION <br /> FARM O 4 PROCESSOR [?'S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) HONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> c JRrAf-5 Zo5 gs$-233 <br /> NIGHTS: NAME(LAST, RST) PHONE WITHAREACODE NIGHTS: NAME(LAST.FIRST) <br /> PHO <br /> SGML <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME // CARE OF ADDRESS INFORMATION <br /> /�aAo tG ca - /f 74460 /9*1?_ ` L <br /> MAILING OR STREET ADDRESS ./ / ✓�x MNid6aN INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> C1I9�Ix/l s TC- Z. CORPORATION 0 PARTNERSHIP [ OUNTYAOENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 5r5330 zo9 FryB -z33 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER T CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADUHESS ✓�x b1M�N D INDIVIDUAL QLOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP =COUNTY-AGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HQ 4 P4 - d y 8 8 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ E xbindi a ITSELF-INSURED [__1 2 GUARANTEE 0 3 INSURANCE L_j 4 SURETYSOND <br /> =5 LETTEROFCREOT =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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= 11.I1/ III. <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 MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> �] D D S o] <br /> LOCATION CODE -OPTbNAL CENSUS TRACT# -O � SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> II <br /> FORM A(5-91) FOR003745 <br /> L� `" ' v <br />