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STATE OF CALIFORNIA - <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a <br /> � V <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION Ve7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-] 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 51 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF CILI NA E /���G NAME OF OPERATOR <br /> O 6 W <br /> ADDRESS NE/ $Si $SSWI P ELp10PfI <br /> 5 a� riVe, // CS(�, /05036-�l <br /> CITY NA STATE ZIDE� SITE PHONE#WITH AREA CODE <br /> iol�evdnl i; CA <br /> TO INDICATE D CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TA AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> [NIGHTS: <br /> AYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) A WITH AREA rnnF <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> Ry11L/\rayl <br /> NAME CAREOFADDRESS INFORMATION <br /> MAILING RSTREEETLTT DDRES ✓ box ID Ind 0 INDIVIDUAL LOCAL-AGENCY 0STATE-AGENCY <br /> zM `- yJay 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NA STAT ZIP CO OE# ITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME O OWNE If CARE OF ADDRESS INFORMATION <br /> I <br /> MAILIN RSTREET App RESS lO - ✓ box 0indicate D INDIVIDUAL <br /> /✓�6 l/ = LOCAL-AGENCY 0 STATE-AGENCY <br /> r CORPORATION 0 PARTNERSHIP =COUNrYAGENCV Q FEDERAL-AGENCY <br /> CITY N i G aTATF ZIPCOM /) / PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBEI/R-IyCall(916)3/3223-99✓55555 if questions arise. <br /> TY(TK) HQ F4—F4]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPL TED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ box Windicate O I SELF INSURED Q 2 ARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTEROFCREDIT EXEMPTION O 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 ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 it.V III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAM E(PR INTED B SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# eT101&tl <br /> URISDICTION Al ACILITY It <br /> � H A4 r-s q fa <br /> LOCATION CME OPTIONAL CENSUS TRACT SUPVISOR DISTRICT CODE -OP <br /> THIS FORM MUST BE ACCOMPAN AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A5 ^\ <br /> �� �� <br />