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• • pebouace <br /> STATE OF CALIFORNIA �'^ <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD i-'�, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w��. `° <br /> COMPLETE THIS FORM FOR EAC ACILrTYISITE <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT = 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 9 <br /> 81 <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DS RFACILITYN E ^� / NAME OF OPERATOR — <br /> AD RES S V NEAR EST CROSS STREET PARCEL#(OPTIONAL) <br /> ��tld W. <br /> So�Drq <br /> C—y�pME � <br /> STATE A ZIPf,OD 2 ) 2 ITE P01 Na HONE .WITH AREA ODE <br /> -2— <br /> /J'VTNO INDICATE 0 CORPORATION l� INDIVIDUAL l= PARTNERSHIP LOCAL AGENCY ISL] COUNTY AGENCY STATE AGENCY IQ 55-2- <br /> T <br /> TS <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR 0 RESERVATION AN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NiA $Ty <br /> NAME(LAST,FIR � / PHONES WIT lj ARE A COD DAYS: NAME(LAST,FIRST) — <br /> WITH AREA CODE <br /> NIGHTS:: NAME LAST,FIRST) PHONE#/-WITH I AREEAA CODE NIGHTS: NAME(LAST,FIRST) CODF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME/(' D �` CARE OF ADDRESS INFORMATION <br /> MAILINLL RST ET ADD RESS r6n ✓ Oox bindicaW O INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Z �a ra 3/� O CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL <br /> CITY NA E 'KSTyT�, ZIP CO� +2 n� PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /�' IW !J l/ <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0indule [7:1 INDIVIDUAL (] LOCAL-AGENCY D STATE-AGENCY <br /> D CORPORATION Q PARTNERSHIP Q COUNTY AGENCY O 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 - Q Z Z y <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0indicate 1 1 SELF INSURED ox GUARANTEE Q 3 INSURANCE [1]4 SURETY BOND <br /> L-15 LETTER OF CREDIT 6 EXEMPTION I= W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II i hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.E I.Ev 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 B SIGNATURE) APPLICANT'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# =�— JURISDICTION# FACILITY It <br /> LOCATION CbE -OPTIONAL CENSUS2ACTIt -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL V' r <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) FOR0033A 5 <br /> 1 <br />