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0 • l4eWp • C <br /> f <br /> STATE OF CALIFORNIA 'o <br /> STATE WATER RESOURCES CONTROL BOARD W�yg :o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM A >f w <br /> COMPLETE THIS FORM FOR EACH FACILTrYISTTE °"'°""�` <br /> MARK ONLY t NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSE SIT q 1 <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> GiT r s=oy' <br /> ADDRESS NEAREST CROSS STREET PMCELNIOPfX)NAy <br /> 00/_ <br /> .ST. <br /> CITU NAME STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> Z,f>6 CA 9 Zell <br /> I/ <br /> T INDICATE 0 CORPORATION INDIVIDUAL = PARTNERSHIP O L <br /> LOCAAGENCY O COUNTY-AGENCY' O STATE AGENCY' [--]FEDERAL-AGENCY' <br /> DISTRICTS' <br /> 'It owner of UST Is a public agency.corrplele the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR 0 RESERVATION #OF TANKS AT SITE E.P.A. I.D.s(optimal) <br /> 3 FARM O 4 PROCESSOR 5 OTHER ORT RUSTLANDS ' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> TAL Gv6 1Pq WITH AREA— 7� <br /> NIGHTS: NAME(LAST,FIRST) PHONE# CODE NIGHTS: NAME(LAST,FIRST) PHONE it WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> GI, Tv li 06 <br /> MAILING OR STREETADDRESS ✓ box bindicale D INDIVIDUAL i� LOCAL 0 STATE-AGENCY <br /> Soo 6 I�CORPORATION O PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 95Zy/-/ qia <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER ^^ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AOD ESS /J `� boxb indicate O INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> Q Z-j6 CORPORATION O PARTNERSHIP = COUNTYAGENCYFEDERALAGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME C4 -5;, Z 2/ /'5/D <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 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 IMbate 0 1 SELF INSURED 2 GUARANTEE (] 3INSURANCE O 4 SURETY BOND <br /> I� 5 LETTEROFCREDIT O S EXEMPTION 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'STRLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY q <br /> COUNTY N JURISDICTION#(514 1 I G <br /> o e b 9 -7 <br /> -LOCATION CENSUS TRACT# -OPTIONAL 9UPVISZDOR-DISTRICT CODE -OP <br /> C77 �- 90 � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATWNB///��� FaRM4V <br /> FORM A(311113) <br /> �I <br />