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-LryOuw <br /> STATEOFCAUFORNIA s <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A " <br /> COMPLETE THIS FORM FOR EACH FACUTYISITE <br /> MARK ONLY 1 NEW PERMIT 1 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE ITEM [::] 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> s <br /> I ed <br /> ADDRESS NEAREST CROSS STREET PARCEL r(OPTIONAL) <br /> 0 Cao 5 <br /> CITY NAMESTATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> Sew CA ?.a _ _ o <br /> v BOX <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY [] STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION a 2 DISTRIBUTORQ RE <br /> F NO ION x OF TANKS AT SITE E.P.A. L O.m(aprional) <br /> ® S FARM C 4 PROCESSOR 5 OTHER AT OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> GAYS: NAME(LAST,FIRST) PHONE m wITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE r WITH AREA CODE NIGHTS: NAME{LAST,FIRST) <br /> PH r <br /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAIL,NGOR.STREET ADDRESS ✓ boa loindimG [_-I INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP [] COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Cai c wxw-u Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q GED£RAL-AGENCY <br /> CiTY NAME STATE ZIP CODE PHONE*WITH AREA CODE <br /> 1V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 T- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY.-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ but)Mkaa Q 1 SELF-INSURED Q 2 GUARANTEE = S INSURANCE Q 4 SURETY BONG <br /> D S LETTEROFCREDIT Q$EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box l or I1 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= IL❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL CANT'S NAME(PRINTEO a SIGNATURE) APPLICANT'S TITLE DATE MONTwOAYNEAA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION a FAC ILn-Y# <br /> IV tr1 <br /> LOCATION CODE -OPrlONAL CENSUS TRAC a -OPTIONAL SU Pv OR-DI T CODE -OPTIONAL <br /> W kD <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(3)OR MORE PERMIT APPLICATION FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) FORA-S <br /> rIv�r�u <br /> 1 - <br />