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ebo a <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD �� a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ron ' <br /> COMPLETE THIS FORM FOR <br /> ���A <br /> EACH FACILRY/SITE <br /> MARK ONLY 1 NEW PERMIT � I)cl� <br /> 3 RENEWAL PERMIT S CHANGE OF INFORMATION ] PERMANENTLY C <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT [_] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MU COMPLETED) \ <br /> DBA NAM <br /> ORF ILITY /y� L NAME OF OPERATOR <br /> �[Cr✓L. &Uv IVfA1l J'f� '56'W" <br /> ADDRESS N REST CRO;S TREET PARCEL 9(OPTIONAL) <br /> 2rrb r C. (se e w 0,il <br /> CI W N MEI STATE ZIP CODE PITE PHONE#WITH AREA COD <br /> G.u{-eta CA 3 (10S) fi2t;- 7iZOV <br /> TO INDICATE CORPORATION 0 INDIVIDUAL Q PARTNERSHIP,. LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY ED FEDERALqQENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS0 1 GAS STATION 0 2 DISTRIBUTOR 4 ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. /I.D.cx(optional) <br /> 0 3 FARM O 4 PROCESSOR OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAPg IN ST,FIR T) PHO Ex WITH AREA CODE DAYS: NAME(LAST,FIRS) <br /> ��jj t11 O�u (Z�9 62r-;ZED <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE;WITH AREA CO <br /> IF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA E <br /> Se( CARE OF ADDRESS INFORMATION <br /> MAILING OR STR ET ADDRESS ✓boz bintlicale INDIVIDUAL LOCAL-AGENCY STATE-A ENCY <br /> CORPORATION Q PARTNERSHIP <br /> O COUNTY-AGENCY E:] FEDEM-AGENCY <br /> CITAACW I e Qµ SAZIP DES6 PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA FOW EcR <br /> of St(�, i�Ls+ , CARE OF ADDRESS INFORMATION <br /> alncn <br /> MAILING OR STREET ADDRESSr�? ✓ box Io ndkale 0 INDIVIDUAL LOCAL-AGENCY Q STATE-A ENCY <br /> f•D . i OJ <br /> 'k ' 0 CORPORATION 0 PARTNERSHIP 0 COUMY.AGENCY 0 FEDERA-AGENCY <br /> CITY N / STAB � <br /> , ZIP WDEZ,; PHONE It WITH AREA CODE <br /> GA4 Cp SCR H <br /> (294 1 AZT• <br /> IV.BOARD OF EQUALIZATION UST SSTOORR�A,G�E FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 ,I� I F LSCI <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkale 0 1 SELF INSURED 2 GUARANTEE 0 3 INSURANCE <br /> 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION 99 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 /> THIS FORM HAS BEEN COMPLETEb UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT / <br /> APP ICAC n NAT)(PSN ED"IGNAT RE) �PLIC�S TIr � �^ DAT r �ONTH/DAYNEAR / <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION OP <br /> FORM A(5-91) <br /> F/ <br />