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• • a <br /> STATEOFCALIFORMASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM AA COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-� 2 INTERIM PERMIT Q 4 AMENDED PERMIT Ej e TEMPORARY SITE CLOSURE <br /> 9 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OSAO FACILITY NAME NAME OF OPERATOR <br /> t���iF.� co.9s r i°.e>ad <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3 5 S. s'ibc�o <br /> CITYNAMESTATE ZIP CODE I VTEPHONE A WITH REA CODE <br /> 4,04-T' CA 95ZI/ BOX <br /> �{ cic/j <br /> T Nq TE 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY' (]STATE-AGENCY' O FEDERAL-AGENCY' <br /> 11 mineral UST is a public agency,mmplele the following:narre of Supenieor of dHlssection,n,section,DISTRICTS'n,w offim which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN is OF TANKS AT SITE E.P.A. I.D.N(optimal) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACTPERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITyy AREA COD DAYS: NAME(LAST,FIRST) - PHONE N WITH AREA CODE <br /> �/ f)!7 �J^Sl// <br /> NIGHTS:"NST.FIRST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE 8 WITH AREA CODE <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ,Nn ` �� CARE OF ADDRESS INFORMATION <br /> c/ <br /> MAILING OR STR ET TSS _ n ✓ bwbindkaw 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> Z7/ V Fr" Ary V CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE ON N WITH AREA CODE <br /> �� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NA OF OWNER CARE OF ADDRESS INFORMATION <br /> ef l� � <br /> MAILINGOR STREET ADORES SS ✓ box bindkaN O INDIVIDUAL O LOCAL AGENCY 0 STATE AGENCY <br /> ' /30 M1 / 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAMESTA ZIP CODE PHONEE WITH AREA CODE. <br /> G o✓o—r- O337! 7[ n <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - �I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ box to Wd ate (] 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE <br /> O u x SURETY BOND <br /> 5 LETTER OF CREDIT <br /> O 8 EXEMPTION O 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: I.D IL❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# �FACILITY# T <br /> M1 I I If 1661-71 <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) f <br /> A pl� IXieW7AJl7 <br />