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• STATE OF CALIFORNIA `'•s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> LLL/// ri <br /> COMPLETE THIS FORM FOR EACH ACILITYISITE _ <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT a�rS CHANGE OF INFORMATION ❑ 7 P Y OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE 5/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME �I'LQ NAMLOFOPERA9TOr) OF- � L�� M`� <br /> ADDRESS F -A A VC/ NEAREST CROSS IS EET 7 PARCEL#(OPTIONAL) <br /> CITY NAME V STATECA t ZIP JDE �� SITE PHONE N WITH AREA CODE <br /> BOX <br /> TOINDICATE CORPORATION O INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY (]COUNTY-AGENCY STATE-AGENCY O FEDERAL-AGENCY <br /> OSTIBCTS <br /> .TYPE OF BUSINESS O i GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR OTHER RESERVATION <br /> O 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) ij^/3— 70 7/ <br /> AA eaM L I Zo°i - 8 o L,C Zw j 1,6 l% <br /> NIGHTS: NAME(LAST,FIRST)I PHONE#WITH AREA OE NIGHTS: N E(LAST,FIRST) <br /> PHONE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b Wmw O INDIVIDUAL O LOCAL-AGENCY Q STATE AGENCY <br /> CORPORATION Q PARTNERSHIP O CWNTY-AGENCY a FEDERAL-AGENCY <br /> CIT'NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMicale 0 INDIVIDUAL O LOCAL AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F41_4]- <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm biMkale Q 1 SELFANSURED [:12 GUARANTEE O 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTEROFCREDn Q S EXEMPTION O 99 OTHER <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.[:] U.O 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL ICANT'S NAM E(PR IN TED&S IGNATU RE) gPPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> MM AIvT60 <br /> LOCATION CODED OPTIONAL CENSUS TRACT# —17ONAL SUPVISOR- [STRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY//AAT LL7LEEA0STT(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FOR0033A-5 <br />