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• OV" p <br /> STATE OF CALIFORNIA of <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> /r !' vFGav-r <br /> ADDRESS NEAREST CROSS STREET PARCELN(OPTX)NAU <br /> CITY NAME ' STATECA ZIP / ,1 !/ IHQNF�i♦♦�RE Ci p� <br /> Box ATE 0 CORPORATION 0 INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY (,�COUNTY AGENCY E--] STATE-AGENCY [=1 FEDERAL A ENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 0 RESERVATION <br /> O 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 1i�01 FfeE DEdr owl <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODEF NIGHTS: NAME(LAST,FIRST) <br /> fl. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME-1-7— CARE OF ADDRESS INFORMATION <br /> �T� G�'JT- <br /> MAILINGORSTREETADDRESS / T ✓ bexbllbleab L INDIVIDUAL LOCALAGENCY I� STATE AGENCY <br /> 2Z f ��• ��TAL/� 5- - Q CORPORATION 0 PARTNERSHIP E-1 COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#W AREA CODE <br /> 'pa� �j� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS <br /> • ✓ box binCicale Q INDIVIDUAL LOCALAGENCY [7:1 STATE-AGENCY <br /> ZZ/ L!�• ®S CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME^T STATE`� Z4`OfDEp ONE#WITH AREA <br /> /C�.OD,Er/ <br /> G Y C+�TI <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxloindicale [� 1 SELFINSURED l�2 GUARANTEE E--13 INSURANCE O 4 SURETYBOND <br /> L <br /> 5 LETTEROFCREDIT [�j 6 EXEMPTION E] 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 the ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D I. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> it � -_ <br /> cjI EEC T3[l7]taop 12 <br /> - - -- ---- <br /> LOCATI N COD OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> O� � 23, ga <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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETANK REGULATIONS <br /> • � FDR0033AR6 <br />