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Uj <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />enuDI FTF THIS FORM FOR EACH FACILITYISITE <br />I. FACILITY/SITE INFORMAT IUN&AUunwa -tmual DQ VVrn'a.-. r --A <br />❑ 1 NEW PERMIT <br />❑ 3 RENEWAL PERMIT <br />❑ 5 CHANGE OF INFORMATION ❑ <br />7 PERMANENTLY CLOSED SITE <br />MARK ONLY <br />ONE REM <br />❑ 2 INTERIM PER <br />❑ 4 AMENDED PERMIT <br />❑ 8 TEMPORARY SITE CLOSURE <br />NEAREST CROSS STREET <br />I. FACILITY/SITE INFORMAT IUN&AUunwa -tmual DQ VVrn'a.-. r --A <br />NAME OF OPERATOR <br />nRA OR FACILITY IN <br />' t, A S FG / G.N� • <br />NEAREST CROSS STREET <br />PMCELS(OPrgNAI) <br />ADDRESS /t _� A✓� <br />s9�Cd cXiG <br />CITY NAME <br />STATE ZIP CODE <br />V ZZA/) <br />SITE PHONES WITH AREA LADE <br />333 —98 <br />GOA= <br />CA <br />✓ BOX CORPORATION INDIVIDUAL =1 PARTNERSHIP <br />O LOCAL -AGENCY ED COUNTY -AGENCY ' <br />O STATEAGENCY- ED FIEDEML-AGENCY' <br />TO INDICATE \l' DISTRICTS' <br />age ey, oon4lde the IOir office which operates the UST <br />' d UST la a timing: narre of Supervbot of division, section. o <br />If owner pudic <br />a ✓ IF INDIAN A OF TANKS AT <br />SITE E. P. A. I. D.* (apfimmaq <br />TYPE OF BUSI NESS [fit GAS STATION 2 DISTRIBUTOR <br />❑ <br />RESERVATION <br />u ` <br />❑ 3 FARM ❑ 4 PROCESSOR ❑ <br />5 OTHER OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMAHT) rmc <br />DAYS: NAME (LAST. FIRST) PHONE S WITH AREA DE DAYS: NAME (UST, FIRST) PHONE S WITH AREA CODE <br />pGihST ZoroiT 3�3—g& <br />PHONES WITH Afl A CODE NIGHTS: NAME(LAST, FIRST) PHONEA WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST)�g <br />It. PROPERTY OWNER INFORMA ION- MUST BE COMPLETED ZZ <br />MATION <br />NAME <br />//I S A , t(i4SoGi <br />INDIVIDUAL l� LOCAL -AGENCY 0 STATEAGENCY <br />MAILING OR STREET ADORES <br />CORPORATION PARTNERSHIP COUNTY AGENCY AC FEDERAL AGENCY <br />CITY NAM STA Pn� VHONE.01 AREA CODE <br />�07A �Tv --?& WDA <br />Lr iJ 1fS2� ;'z <br />— <br />CITY <br />TANK OWNER INFORMATION - (MUST BE <br />y (1, <br />,-- `--- •- ✓ box 10iuscala <br />iR STREET ADDnRESS (] INDIVIDUAL O LOCAL STATE -AGENCY <br />R AGO {//C s • %• O CORPORATION Q PARTNERSHIP = COUNTY AGENCY (] FEDERAL -AGENCY <br />STATE ZIP CODE PHONE S WITH AREA CODE <br />ov2A i1���S �4 �/i3P <br />_------ ___. -ne see A nnnl utT AN IRAQ FR.(..nll 10161722-9669 if auesfionsarise. <br />IV. DUAMIJ ur mmvn61cn <br />TY (TK) HO 4 4- - p 6 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY • (MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br />1 SELF-INSURED 0 2 GUARANTEE E3 3 INSURANCE Lj 4 SURETY BOND <br />✓ box bindicate O 5 LETTER OF CREDIT 6 ExEMPTION O 66 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: <br />I.❑ II.❑ In. <br />r..i� rn^aS unc RFFAI rnAAPI FTED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />LVValL nvu-v��•-�.•�• - <br />COUNTY N JURISDICTION R FACILITY All <br />LOCATION CODE - OPTIONAL ( CENSUS TRACTS -OPTIONAL SUPVISOR DISTRICT CODE OPTIONAL " Y I / <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM Ba UNLESS THIS IS A CHANGE OF SITE INThRMAVON ONLY. <br />xmeenenuun CTno ACF TAHI( RFC ATI <br />OWNER MUST rlLt I MI5 runm at I n inc -wra <br />FORM A (393) 0 <br />