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• "ssooa e. <br /> STATE OF CALIFORNIA °o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC ACILrrY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 A AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> I NAME­OF <br /> I V/KSS <br /> ADDRESS NEAREST CROSS STREET RWCE COOPTIONAL) <br /> �c_A-AcI CV, x <br /> CITU NAME STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> CA 9�Zor, <br /> ✓ BOX <br /> TO INDICATE D CORPORATION [__1 INDIVIDUAL D PARTNERSHIP D LOCAL-AGENCY <br /> D COUNTY-AGENCY D STATE-AGENCY D FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION D 2 DISTRIBUTOR ✓ IF INDIAN p OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> ON <br /> 3 FARM O A PROCESSOR Y1 5 OTHER OORTRUSTLANIDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Lv, se - [via 2v7 Y 3 -'/oY9 <br /> NIGHTS: NAME(LAST,FIRSTti— PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME s CARE OF ADDRESS INFORMATION <br /> SGt J) S <br /> MAILING OR bREETADDRESS ✓ boxbimicam D INDIVIDUAL LOCAL-AGENCY <br /> D CORPORATION Q PARTNERSHIP FEDERAL-AGENCY D STATE--AGENCY <br /> D COUMVAGENCY DFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> 'C <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box biMkale D INDIVIDUAL D LOCAL-AGENCY <br /> v—& -ir D CORPORATION L�STATE-AGENCY <br /> D PARTNERSHIP DCOUNTY-AGENCY D FEDERAL-AGENCY NAME <br /> STATE ZIP CODE PHONE✓f WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE <br /> OORIAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 x 16G 4(o� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box mintlicale [ I SELF INSURED E] 2 GUARANTEE D 31NSIIRANCE <br /> D 5 LETTER OF CREDIT D 6 EXEMPTION C [__1 d SURETY 60N0 <br /> 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 chec <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1-0 II. III.D <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 8 SIGNATURE) APPLICANT'S TITLE DATE MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY `� <br /> COUNTY R JURISDICTION It p <br /> 3i9 1 L ! 23 aJ <br /> -- CTTIONAL <br /> LOCATION CODE OPTIONAL CENSUS TRg9 �OPSUPVISOR DISTRICT CODE -OPTIONAL <br /> _ -- <br /> O/ Z3� 323 Co 71,;11/e,-i <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. n <br /> FORMA(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS \'1� <br />