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STATE OF CALIFORWA :� •, <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE ' <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED'SITE <br /> 77 <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE s L— <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORFA LITYNAME NAME OF OPERATOR <br /> 2-v r S <br /> ADDRESS L 2NEAREST CgQSS STREET PARCEL A(OFiCAL) <br /> �J\ <br /> CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 95 z tv <br /> ✓ Box <br /> TOINDICATE 9219FPORATION D INDIVIDUAL 0 PARTNEAS14P D WCALASENCY COUNTY-AGENCY' O STATE.AGENCY' l�FEDERAL-AGENCY' <br /> ' <br /> It wvner d UST Is a public agency,complete the following;name d Supervisor of tlNlebn,section,DISTRICTor office which operates the UST <br /> TYPE OF BUSINESS [EfGAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A, I.D.a Lspdamo <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 6 OTHER OR TRUST LANDS 00(),n 14/ 7,5C) <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS' NAME( ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �A—c—lC 61D '4v7a N8 <br /> NI T : NAME( T,FIRST) p PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �jjo qy T�qS <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME n _ CAR DDRESS <br /> INFORMATO <br /> MAILI ON <br /> RED0 INDIVIDUAL LOCAL-AGENCY 0 STATEAGENCYbObON <br /> O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL#GENCY <br /> CITY NAME 3 TE ZIP E PHONE#WITH AREA CODE <br /> �.4 �� s v z �s� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> WTnFOVVNE'R CARE OFA SS INFORMATION <br /> M OR STREET ADDRESS ✓ bm bMtlkaw INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> (J 9:J-e10PoMTION 0 PARTNERSHIP COU TYAGENCY FEDERAL-AGENCY <br /> CITY N 3 TE ZIP CODE PHONE#WITH AREA CODE <br /> - �3 s/D �lzgco9r <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4-F4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b Wiwte 0 1 SELF-INSURED 0 2 GUARANTEE E E:]4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 S EXEMPTION O IN OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 1.97T <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> NER'S NAME(PRINTED A SIGNED) OWNER'S TITLEDATE MIT AYNEAR <br /> 'No c.r--/J Ln .� <br /> LOCAL AGENCY USE ONLY L- ,oc.kkA.vZnL. <br /> COUNTY# JURISDICTION# FACILITY 4q�6 <br /> 53 = Fe6ojo34 3 I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTAONAL <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 /> FORMA <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK.�REG LA <br /> FGRWJ7AJn <br /> (393) <br /> 3d <br />