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a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOROR FACILITY //✓{.Ti/L NAMEOFOPERATOR <br /> ADDRES4ve> NEAREST CROSS STREET PARCEL#(OPrIONAQ <br /> CITU NAME STATEZIPZI� E� qv <br /> 04>gy 60Tj EA4CJODE_ ,. <br /> I/ BOX <br /> TOINNDICATE D CORPORATION O INDIVIDUAL O PARTNERSHIP 0 LOCAL AGENCY 0 COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR0 RESERVATION,/ <br /> ESERVADDION #OF TATS AT SITE E.P.A. I.D.#(optional) <br /> ❑ 3 FARM 0 4 PROCESSOR OTHER OR TRUST LANDS 111 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: zo,, ? <br /> OP7�#` CA <br /> AREAOE6 DAYS: NAME(LAST,FIRST) <br /> PHONP I WITH AREA M119 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ow-mm C E&P� <br /> AILING OR STREETADORESS �,(..�— ✓b#xbindlcal# CD INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (�� /y / Ej CORPORATION = PARTNERSHIP 0 COUMY-AGENCY FEDERAL-AGENCY <br /> CIT)AME ST T ZIP CODE HONE#WITH AREA CODE <br /> d • 1%5 Za. 3Fs1 -32 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> / enlsAcvEEL' <br /> MAILING OR STREETADD�R-E,SIS ✓ box binftata O INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> 12p/7 �'GG/y Q CORPORATION PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE fe� PHON,)1'20AREA CODE <br /> /C�-�LVL- .2X/.Tis( <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 BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SUREN BOND <br /> D 5 LETEROFCREDIT Q 6 EXEMPTION (]W 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYtYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> L TION CODE -OPTIONAL CE SUS TRACT# -OPTIONAL SUPVI�SfO�DISTRICT CODE OP ONAL �• �� <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNL IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOROD33A5 <br />