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oXes <br /> STATE OF CALIFORNIA `4 <br /> STATE WATER RESOURCES CONTROL BOARD - ^o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> n `XxIeOXM X <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ] PERMANENTLY C <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ff <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACT TY AME <br /> 7 T OF GOUJ775 EGU NAME OF OPERATOR <br /> x <br /> p.Q�� �O� vTnl F <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPtIONAL) <br /> CITYNgr�IE �O STATE ZIP CODE TE PHONE#WITH AREA CODE <br /> �LAtl�•-r_ CA g5zzo Tia z7-58'6 <br /> TO INDICATE D CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY <br /> D STATE-AGENCY FEDEflAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS E:—]j STATION F 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(op(ionaq <br /> ,L=J/ RESERVATION <br /> 3 FARM L=j 4 PROCESSOR O 5 OTHER OR TRUST LANDS 3 ze, ~pp <br /> 3' / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LA T,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �Evy'�' 27586 <br /> NIGHTS: NAME(LAS .FIRS PHONE#WITH AREA CO NIGHTS: NAME(LAST.FIRST) A WITH AREA CnnF <br /> 2�) 369-dO$ <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> G / /E O•CGVvl�j G� uG.� <br /> MAILING RSTREET ADDRESS / ✓box bin#kale INDIVIDUAL 0 LOCAL AGENCY 0 STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITU NA� ��� $�_7A ZIP�CODE� PHONE <br /> 7Z7-[WITH AREA CODE—� <br /> � 41 <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> N!AEOF OWNER- ^ CARE OF ADDRESS INFORMATION <br /> LL/� <br /> MAILING OR STREET ADDRESS ✓ boxbiMbale Q INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> Ute' �/� D CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1727-58'6 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4�- � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 10 indkale E:1 I SELF-INSURED 0 2 GUARANTEE ���3I3INSURANCE E714 SURETY BONG <br /> l� 5 LETTER OF CREDIT 0 6 EXEMPTION � 9g 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: I.❑ II.❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PH INTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FFACIILITYY�� TY�• # <br /> LOCATION CODE -OPTIONAL CENSUS TRACT I -OPTIONAL <br /> SUPVISOR-DISTRICT CODE <br /> v7 Z Z '7 �7 <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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAT <br /> • • IONS FOR0033A RE <br />