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4(,OVR fB CG <br /> STATE OF CALIFORNIA �P <br /> STATE WATER RESOURCES CONTROL BOARD i�, .. � <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A r oe <br /> y a <br /> "ry o . <br /> ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION� 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT FI 6 TEMPORARY SITE CLOSURE 6Q <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME - NAME OF OPERATOR <br /> Estate of Louis DeLuca Davy, Devine <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OFTbNAL) <br /> 14248 E Peletier Road SOkt l <br /> CITY NAME STATE ZIP QODE SITE PHONE#WITH AREA CODE <br /> Acamoo CA "LLJ 209-727-5864 <br /> TO BOX O CORPORATION n INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY AGENCY I[7 STATE AGENCY QFEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optionall <br /> ESEON <br /> 3 FARM = 4 PROCESSOR = 5 OTHER OR TRUSTVAND $ 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Dave 209-727-5864 <br /> N IGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> , Dave ^^._�Q-0059 PHONE#WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> of Louis DeLuca <br /> MAILING OR STREETADDRESS ✓ box bindlcaro INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> 1 , 9 . R O X 313 CORPORATION 0 PARTNERSHIP = COUNTY AGENCY 7] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ,d , CA CA 95237 14 <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _state of Louis DeLuca <br /> MAILING OR STREET ADDRESS ✓-box Io Indicate INDIVIDUAL LOCAL AGENCY 0STATE-AGENCY <br /> P . O . BOX 316 O CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY Q FEDERAI.-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> CA °-.'37 209-727-5864 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓bac 0Indicate O 1 SELF-INSURED [__]2 GUARANTEE 0 3 INSURANCE [__1 4 SURETY BOND <br /> 5 LETTER OF CREDIT L:]6 EXEMPTION ] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'SNAMF,(RINTED&SIGNATURE;) h��1.�1 , APPLICANTS TITLE DATE MONTWDAYNEAR <br /> E C. <br /> 1,404. / (moo 11/20/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY# <br /> LOCATIONCODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -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(5-91) FOR003334-5 <br />