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teWe <br /> STATE OF CALIFORNIA .r� ` <br /> STATE WATER RESOURCES CONTROL BOARD l '� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 'ao� '° <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE ' �,�1Oe,,,.' <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO ED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 1 NAMEOFOPERATOR <br /> 1 <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL#JOPTIONAL) <br /> 6-1-1c;t�jr �c t7/� <br /> CITY NAME <br /> x� STATE ZIP CODE TE PH E i WITH AREA CODE <br /> CA G! 2rlZ _0 J .-4'73© <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL (]PARTNERSHIP E] LOCAL-AGENCY E:l COUNrYAGENCY' O STATE AGENCY' <br /> 'll Owner UST leapublic agency,mnpletethe/011owln :name of Su DISTRICTS' I� fEDERA4AGENCY' <br /> g pam,sor of d"iun,section,or Office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.,t(opfimalJ <br /> 3 FARM ❑ a PROCESSOR = 5 OTHERRESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYSEMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> : NAME(LAST,FIRS PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRS <br /> (Z0f) ��V _4 SZ) T) PHONE WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) ` PHONE•WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE:1 WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /kA1G �F <br /> MAILING OR ST ET AD RES_ ✓ boa 0Niue <br /> ^7'7—7 C4 C T7A0 INDIVIDUAL E-1LOCAL-AGENCYSTATE-AGENCY <br /> CITY NAME CORPORATION ED PARTNERSHIP I] COUNTY AGENCY Q FEDERAL AGENCY <br /> STATE ZIP CODE PHONE N WITH AREA CODE <br /> Loft 7-1S -47�;o <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NA,/ME OFF/ L <br /> OJWN,ER a CARE OF ADORES INFORMATION <br /> MAILING OR STREET ADDRESS ✓ <br /> J ,l boa b indbate <br /> INDIVIDUAL LOCAL AGENCY <br /> I1 STATE AGENCY <br /> CITY NAME <br /> 0 CORPORATION E:] PARTNERSHIP = COUNTYAGENCY =1 FEDERAL AGENCY <br /> STATEZIP CODE HONE A WITH AREA CODE <br /> 1100 CA g� 7T� �9 tf7 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4- -Q� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box bindbate 0 I _ELF INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> El 5 LETFER OF CREDIT =6 EXEMPTIONO<SURETY BOND <br /> W 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. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE <br /> DATE MONTWDAYfYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION If FACILITY f <br /> D (P400l �'.� All <br /> LOCATION CODE -OPTIONAL CENSUS TRACT ' -OPTIONAL <br /> ':9K) 7 <br /> �Z suPYlsoR-DIsrR�cr coDE -aPnoNAL <br /> 'Zv <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THE IS A CHANGE OF SIE INFORMATION ONLY. <br /> FORMA(3fe3) <br /> OWNER MUST FILE THE FORM WITH <br /> E LOCAL AGENCY IMPLEMENTING THE UDERGROUNQ,4TO• RAGE TANNS FOR0077AJi <br /> K REGULATION <br /> // <br />