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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A w �e <br /> COMPLETE THIS FORM FOR EACH FACILITY SL <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORF ITYNAME ` NAME OF OPERATOR <br /> U 1 <br /> ADDRESS �D Q� N`E'AREST CROSS STREET P37EL#� A�II ^ <br /> CITY NAME /^ STATE ZIP CO�DE� SITE PHONE#WITHAREA CODE <br /> oD CA 4 D ail - <br /> TOIN BO TE O CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY f� COUNTY-AGENCY 0 STATE AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR I= R SEF IND IAN ON #OF TANKS AT SITE E.P.A. I.D.#Iopdwal) <br /> AT <br /> 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST, E DAYS: NAM <br /> FIRST) PHONE#WITH AREA COCOE(LAST,FIRST) <br /> 1-1' <br /> PHONE&WITH AREA COD9 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA nQQP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> W 1 fiir$G<f <br /> MAILI G OR STREET ADDRESS ✓bubindicala VIDUAL =1LOCAL-AGENCYSTATE-AGENCY <br /> Wl7 4�"- �/���' - l�CORPORATION n PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE x WITH AREA CODE <br /> 1_19rz9 GGG����II!11 9 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMFE��oF OWNER CARE OF ADDRESS INFORMATION <br /> �vGli <br /> MAILING OR STREET ADDRESS L ✓ boa bindcaie INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY,NA^MEp�T Sz ZIP CODE �T PHONE x WITH AREA CODE <br /> G// <br /> IV. BOARD OF EQUALIZATION LIST LIST SST OORRAAGGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) H074 4 -�4 E11 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boabiMicale t SELF-INSURED L-1 yGUARANTEE 0 3 INSURANCE O 4 SURETY SONO <br /> 5 LETTER OFCREDT 6 EXEMPTION 0 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II isghecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E II.WfIII. <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&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> ® 1?-60 F= <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# - ISTRICT CODE -OPTIONAL <br /> OPTIONAL SUPVISOR-D <br /> oL � • o <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) FOR0033A5 <br />