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�' • � gggOVA <br /> STATE OF CALIFORNIA W+ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> O�II�OPMIn <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE ! 7- <br /> 1. <br /> Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM NAME OF OPERATOR <br /> i C 4//t/ <br /> ADDRESS NEAREST ROSS REST PARCEL#(OPTIONAL) <br /> O d Sc�©�� Sf s�C jr <br /> CITY NAME ( STATTEA ZIP CODET� / SITE PHONE#WITH AREA CODE <br /> BOX <br /> / S✓ (7 <br /> TOO INDICATE D CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY Q COUNTY AGENCY Q STATE AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> IF INDIAN TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR / 0 R SERVATION #OF TANKS AT SITE E.P.A. 1.D.#(optimal) <br /> 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS G�/) <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PWI WITH APPA MOP <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME n' / / _ CARE OF ADDRESS INFORMATION <br /> N v// /!tel 4 i? <br /> MAILING OR STREET ADL. V boa 0Intlkate INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> Z pS:a a'✓l ►J O CORPORATION D PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME ; STAjEg ZIP C063 bG PHONE#WITH AREA E f <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) J 9 J G <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindbate O INDIVIDUAL LOCAUAGENCY 0 STATE-AGENCY <br /> =CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 O -7 1 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELFINSURED L—I 2 GUARANTEE 3 INSURANCE Q 1 SURETY BOND <br /> D 5 LETTEROFCREDIT O 6 EXEMPTION 99 OTHER <br /> Vl. 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: 1.❑ 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(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHMAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY# N-!fm IC) <br /> 11T = 7y <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -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) FORS <br /> to 0 ,�� <br />