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a <br /> STATE OF CALIFORNIA •STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EAC CILRYISITE <br /> MARK ONLY Q 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SRE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME NAME OF OPERATOR <br /> ADORE' NEAREST CROSS ST�E�n PARCEL/(OPfIONAU <br /> CIN N`AZMj: - U STWWC2/�,Q F9E—2'/ � 317E PHONE#WITH AREA CODE <br /> A.11 Box <br /> TOINDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP D L06AL-AGENCY. D OOUNTYAGENCY 0 STATEAGENCY FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION Q 2 DISTRIBUTOR 1=1 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.A(optional) <br /> 0 3 FARM Q 4 PROCESSOflS ORESERVATION THEA OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYLASi,FIg91f P a�(Wj2 REA CO�z ` DAYS. NAME(LAST,FIRST) <br /> 1 r <br /> 31 E1.WITH ARCA CODE----- <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAIL( GOR STRE/E{T AD,RES9 bobindkne = INDIVIDUAL OLOCAL-AGENCY =STATE-AGENCY <br /> • /r0/a /6D [_1 CORPORATION (] PARTNERSHIP E—] COUNTY-AGENCY ID FEDERAL AGENCY <br /> CITY NAME STATE 21P CODE PpHONE#WITH AREA CODE <br /> GOD r <— <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILAG OR STREET ADDRESS / ✓ Wx blMkale 0INDIVID54 0 LOCAL-AGENCY 0 STATE AGENCY <br /> / •L7• O CORPORATION 0 PARTNERSMP 0 COUNTYdGENCY 0 FECERALABENCY <br /> CITY AME STATE- 21P CODE - PHONE# TH AREA CODE <br /> OD7- f 1/ �z .3G5-3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 If questions arise. <br /> TY(TK) HQ 4 4 !J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa bNka% D I SELF-INSURED []2 GUARANTEE 0 3INSURANCE 0 /SURETY BOND <br /> D 5 LETTEROFCREOIT O 9 EXEMPTION 0 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 BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEOALNOTIPICATIONS AND BILLING: I.❑ 11.0 III.0 <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 a SIGNATURE) APPLICANTS TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT?# -OPTIONAL SUPWSLOU E -OPTIONAL DISTRICT COD /� _I, /� tg <br /> THIS F RM 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"91) FORa939A9 / <br />