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' • <br /> STATE OF CALIFORNIA A• <br /> STATE WATER RESOURCES CONTROL BOARD + <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �.,,,o„w�• <br /> MARK ONLY f NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 6/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR �^ C <br /> / Fe L.` / <br /> ADORES 7/0 /"- ����/� <br /> NEAREST CROSS STREET PMCELA(OPfIONALJ <br /> CITY NAME STATE ZIP CODE SITE PHONE i WITH AREA CODE <br /> La.o:- CA v BOXg'5�1� 333 - 7/9 <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY#GENCY' Q STATE AGENCY' Q FEDERAL AGENCY- <br /> DISTRICTS' <br /> If owner of UST is a public agency.Wnplete the following:name of Supervisor of division,section,or office whIch operates the UST <br /> TYPE OF BUSINESS Q t GAS STATION Q 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT E <br /> SITE .P.A. I.D.a(optional) <br /> Ise,3 FARM Q 4 PROCESSOR 0 5 OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAS ,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> C� A �/ (Z�S') 33 -77/s <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA QULAc NIGHTS: NAMEULbl.FIR51) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa bindkab Q INDIVIDUAL Q LOCALAGENCY 'Q STATE-AGENCY <br /> CG'T/ Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> T 9 'L4/ L - 7/S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa lo Indicate Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> N /D 4.1- . PcG7-, QCORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> /-0,0T Z—/z— Zoe <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4-F4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bindkats Q t SELF INSURED Q 2 GUARANTEE 0 3 INSURANCE <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPPON Q A SUREN BOND <br /> Q %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.a if.[—] III.E] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'SNAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION LADE -OPT/ONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-DISTRICT <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 /> FORMA(393) <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK RESW ATIONS <br /> /��_ FOReW314U <br />