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STATE OF CALIFORNIA G <br /> ��� STATE WATER RESOURCES CONTROL BOARD a t <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA w �` <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT [:] 5 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F—I 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 01 <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) (III <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> M Ar,.S Sal v3 R t S k' e-q 506 N Ook— m A S t'r'j <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2 9 - S-73 0K- N <br /> _CNAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 1�'arvl ca5 �6 -3�� <br /> ✓ 6aX <br /> TO INDICATE CORPORATION INDIVIDUAL I� PARTNERSHPP [] LOCAL-AGENCY [] COUNTY-AGENCY STATE-AGENCY [] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DPSTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#{optional) <br /> RESERVATION <br /> Q 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> y DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> km <br /> CAP <br /> N1 NIGHTS: NAME(LAST,FIRST) PHONE#WdTH AREA C05E_ NIG TS: NAME(LAST,FIRST) ONE a WI <br /> YY1 >�sQ 009 -5 - 0Y1 QAUL rY?AOs v' PH WITH R- tri <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 8 m A as L.?,j <br /> MAIL� p?( L/]rV IN/G OR STREET ADDRESS ,C ✓ box vindicate INDIVIDUAL EJ LOCAL-AGENCY �] STATE-AGENCY <br /> 7 CORPORATION 0 PARTNERSHIP <br /> COUNTY-AGENCY OFEDERAL-AGENCY <br /> CITY N E STATE ODE PHONE E#WITH AREA CODE <br /> `IIIRN CZIPA -is � L �_ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAIL ,OR TREET AD}/DRESS '! ✓ box to indicate Ft INDIVIDUAL 0 LOCAL-AGENCY [] STATE-AGENCY <br /> I y _ E71 CORPORATION [] PARTNERSHIP 0 COUNTY-AGENCY [_�] FEDERAL-AGENCY <br /> CITY ME <br /> ,' S TE ZIP CODE PHONE#WITH A A CODE <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 vindicate CI 1 SELF-INSURED 0 GUARANTEE Q 33.INSURANCE [] 4 SURETY BONA <br /> \ C� 5 L€TTEROFCRECIT 6 EXEMPTION OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boxIQ[. 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 /> ICANT'S NAME(PRIN ED&SIGNATURE) vU) .1 PLICANTS TITLE ? DATE MON[T,�WDAYNEAR <br /> 1 ► � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 5UPVISOR-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) <br /> �j / / FOR4433A-5 <br />