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STATE OF CALIFORNIA _ <br /> STATE WATER RESOURCES CONTROL BOARD - •L'u y�V�`- <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A :" �lo <br /> vY/ <br /> COMPLETE THIS FORM FOR EACH F LMYISITE _ "'"'"�'� <br /> MARK ONLY /L_I NEW PERMIT p RENEWAL PERMIT 5 CHANGE Of INFORMATION ' <br /> ONE ITEM / 7/PERMANENTLY CLOSED SRE <br /> 71 INTERIM PERMIT A AMENDED PERMIT C::] e TEMPORARY SITE CLOSURE �� Q <br /> I. FACILITY/SITE INFORMATION& ADDRESS•(MUST BEC MPLETED) / <br /> DBA OR FACILITY NAME 11-� NAME OF OPERATOR <br /> ADDRESS D G � i/V �'� <br /> NEAREST CROSS STREET I PARCEL A(OPrONAl1 <br /> CIN NAME <br /> 5 /-7- <br /> /J iT CA LP COLE_ SITE PNOL-0 <br /> WITH EA CAo <br /> v BOX <br /> TO INDICATEIJ CORPORATIONC INDIVIDUAL r'1 PARTNERSHIPV LOCAL-AGENCYCOUNfY-AGENCY Cj STATE AGENCY IJ FFDERALAGENCY <br /> NPE Of 3USINESS DISTRICTSk GAS STATION (J 2 DISTRIBUTOR ✓ IF INDIAN a Of TANKS AT SITE E.P.A. L U.s <br /> RESERVATION I h��yl <br /> ESSOR Q 5 OTHER OR TRUST IAN0 <br /> MARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> F WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ;-WITH AREA COCE NNiHT$: NAME(LAST,FRSTI o <br /> i <br /> PH Nc� THA CA c <br /> c1C7 I T BE COMPLETED <br /> �'O � , i GRE OF AOCRESS INFORMATION <br /> 'l <br /> Lac,uAcFNcv <br /> CORPOgATICN ZI PARTNERSHP C: COUNrY.1GENCY CZ STATE.AGENCYL-AGEN <br /> STATE ZIP CODE C FECERA4AGENCY <br /> �`7 ��.u/' I IPHONEA WITH AREA CODE <br /> AC-G W G^ <br /> E COMPLETED) <br /> ���'�/✓- �� v/Y`L� S ✓ Aoa e'mcw Q INONOUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CIN NAME I O CORPoiUTK)N Q PARTNERSRP Q COUNTRAGENCY C FEOEAAL,AGENCY <br /> STATE 121P CODE PHONE A WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION <br /> �UST <br /> jSTORAGE 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 METHOD(S) USED <br /> ✓ f 0111 a 1 SELFlN%RED I1 2GUARANTEE <br /> IJ S LEROFCRETAT Q!EXEMPTION a S E <br /> TTEO r SURENSONO <br /> OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I a II s checked. <br /> CHECK ONE BOX INOICATINO WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BR.LWG: <br /> L 11.0 IIL� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY Cor PEPJURY,AND TO THE BEST CF AIY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP4CANTS NAME(PR W TEO a SIGtNANRE) <br /> APPLICANTS TITLE DATE MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY III, JURISDICTION s <br /> r FACILITY s <br /> LOCATION CODE -OP TpNAL i CT, OP OPTIONAL <br /> v SUPVISOR• (STRICT CODE .OP710 AL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> FORM A("11 <br /> FORMA-5 <br />