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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> A COMPLETE THIS FORM FOR EACH FACILRY/SITE 4A <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT F7 6 CHANGE OF INFORMATION E::] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F-1 2 INTERIM PERMIT E::3 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR <br /> V -# <br /> '162_ <br /> , a / AW <br /> ADDRE75;, NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE 7AP CODE SITE PHONE It WITH AREA CODE <br /> �51vc i CA 150e)el <br /> v BOX <br /> TOINDICATE ;�PORATION E--3 INDIVIDUAL EI PARTNERSHIP LOCAL-AGMY =1 COUNTYAGENCY' STATEAGENCY' =FEDERAL-AGENCY <br /> DISTRICTS- <br /> U owru,r d UST Is a public agony.complate the follo�g:norriti of Supowlsor of division,vocSon.or offloo which operates the LIST <br /> F DIAN IS OF TANKS AT SITE E.P.A. 1.D.4 iaplror�arl <br /> TYPE OF BUSINESS �IGAS STATION = 2 DISTRIBUTOR RE'SERVNATION <br /> 3 FARM = 4 PROCESSOR E:D 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS; NAME(LAST,FIRST) P14ONE*WITH AREA GOD-=-YS: NAME(LAST.FIRST) PHONE*WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE 0 WITH AREA CODE <br /> 11. ROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> CAR�&AIIORESS INFO TIONin <br /> Vow e-4 *n nj�'I Ze. I <br /> MAILING OR STREET ADDRESS V toxioindkom, =1 INDIVIDUAL =3 �V�ff'cj STATE-AGEWY <br /> fo Its j7 E:3 CORPORATION E::] PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY,TE STATE FtE 0 WITH AREA CODE <br /> cell z 30 <br /> 111. TANKOWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER a at S AT- CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 10 indical, INDIVIDUAL 0 LOCAL AGENCY srATE-AGENcy <br /> CORPORATION PARTNERSHIP COUNTYAGENCY FEDERALAGENCY <br /> CITY NAME 8��� P 0 ITH AREA CODE <br /> IV.BOARD OF EQUALIZATION LIST STOR AGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> F <br /> TY(TK) HQ M44- -[6161flo 5 -7 <br /> V. PETROLEUM LIST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> 1 SELF INSURED ED 2 GUARANTEE =1 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCRED(T =s ExEmpnDN = 99 OTHER <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USEDFOR LEGAL NOTIFICATIONS AND BILLING: 1.[-] IL r)� Ill. <br /> THIS FORM 14AS BEEN COMPLETED UNDER PEA14LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) TITLE DATE MONTI-VDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> It <br /> CcUNT-Y# JURISDICTION# FACIL"# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OP77CAUU. SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THE IS A CHANGE OF SITE INIFORMATION ONLY, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) FOR(KI <br />