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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ^ ! o <br /> COMPLETE THIS FORM FOR EACH F ILITYISITE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PER A NTL D E <br /> ONE ITEM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE (JX��o <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OFOP R R <br /> a� Svc% 9L a c� 6s�le <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> p v� <br /> CITY NAME LG��/o STATCA ZIP CODE <br /> S3 3 © SITE PHONE#WITH AREA CO <br /> ✓ BOXp0- <br /> TO INDCATE ]CORPORATION ]INDIVIDUAL I] PARTNERSHIP 0 LOCAL-AGENCY COONTY AGENCY ]STATE-AGENCY O FEDERAL NGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR 0 IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> � <br /> RES <br /> ERVATION <br /> [] 3 FARM � 4 PROCESSOR fJ " OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N E(LAST FIRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> c' _ f( s �( . Zo 8.59-zPHONE#WITH AREA Cr <br /> NIGHTS: NAME(LAST.FIR HONE%NTH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CC <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box 0hdicals ] INDIVIDUAL O LOCAL-AGENCY STATE-kOENCY <br /> Q CORPORATION Q PARTNERSHIP COUNTY AGENCY ] FEDE L-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OFO ` 1 C CARE OF ADDRESS INFORMATION <br /> L11 51` 'PJ <br /> MAILING OR EET ADD SS ✓ box bindbale 0 INDIVIDUAL LOCAL-AGENCY Q STATE- GENCY <br /> CORPORATION O PARTNERSHIP ]COUNTY-AGENCY FEDE L-AGENCY <br /> CITY NAME f�lg STATE ZIP'F3 PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO F4-[4—]- <br /> O Z $ I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxblydkaie 1 SELF-INSURED I]2 GUARANTEE I] 3 INSURANCE ]4 SUREBOND <br /> D 5 LETTEROFCREDT ]6 EXEMPTION HER <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 8E USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it.�'lll. <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&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Ft4oT/ I b I S <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL - <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(5-911 FOROMA5 LoJ�` <br />