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STATE OF CALIFORNIA • '�so�e�: `� <br /> STATE WATER RESOURCES CONTROL BOARD o' <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e `` os <br /> COMPLETE THIS FORM FOR EAC CILITWSITE <br /> MARK ONLY F—I I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F7 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE c7 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED). J� <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PAACEL#(OPTgNAW <br /> r75-1E . FlW /d• <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> (/IC41 CAI/ BOX <br /> 9sds3 ��9 -s3 -a78a <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0,PARTNERSHIP LOCAL-AGENCY D COUNTY AGENCY 0 STATE AGENCY <br /> O FEDEPAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION O ISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#/oohmal) <br /> 0 RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 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 /> C71l� �icLi Rn - 3Y-v7� <br /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE x WITH AREA rrm <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> D o/e, 1r+w f Cep - <br /> MAILING ORSTREET AODRESS ✓box biMkate 0INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> 7 pp 1 `, /� Id, 0 CORPORATION O PARTNERSHIP 0 COUNrY.AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME v STATE ZIP CODE PHONE#WITH AREA CODE <br /> ve C'/,L C/, sass <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b O INDIVIDUAL D LOCAL.AGENCY O STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE 21P CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - p 3 7 7 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE ME (S) USED <br /> ✓ boa Io Mkate 0 1 SELF-INSURED 0 2 GUARANTEE LVJ 3 INSURANCE <br /> 0 5 LETrEHOFCRECIT O 6 EXEMPTION96 OTHER O a SURETYBOND <br /> 0 <br /> VI. 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. 11.❑ III. <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT000E -OPTIONAL <br /> a3 80 3 a-a <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 /> FOR0633A4 <br />