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STATE OF CALIFORNIA -a <br /> ^ STATE WATER RESOURCES CONTROL BOARD {, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A _ `�, !� e <br /> ♦ Y/fes( 0 <br /> y, . <br /> COMPLETETHIS FORM FOR EACH FACILITY/SITE °�,.,-�.. <br /> MARK ONLY T NEW PERMIT G RENEWAL PERMIT Q 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE SITE <br /> ONE ITEM a 2 INTERIM PERMIT d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME Z/,.LNAME OF OPERATOR <br /> .� I� TJ VA ( D h `D'! !✓L FJG�Ov_b Mb, d L14/tK1 /�1c LPpN <br /> ADDRESS NEARqST CROSS r s� PARCEL/(OFf NAZI <br /> CITY NAME STATE ZIP CODEC SITE PHONE A WITH AREA CODE <br /> �I l� CA .137.6 ZG —8 35=76r7 <br /> v Box <br /> TO INDICATE (]CORPORATION O INDIVIDUAL E24ARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY (] STATE-AGENCY FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A- L D.A(optional) <br /> RESERVATION <br /> Q G FARM Q d PROCESSOR 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) 2-1101-1.k3s^—�O�/ <br /> 7z _ F'357-7,2-71 M� �o - <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,F ST) <br /> PHONEe WITH AAC4 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> De c} � awro.JL- <br /> MAILINGORSTREE AOORESS ✓ box ovgkus 0 INDIVIDUAL (] LOCAL-AGENCY Q STATE AGENCY <br /> 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY CD FEOERALAGENCY <br /> CITY NAME STATE ZIP COOS PHONE a WITH AREA CCOE <br /> e <br /> III. TANK OWNER INFORMATION-(MUST IBE COMPLETED) <br /> NAMEOFOWNER Sa�,.�2— A5 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 0imeale INDIVIDUAL ED LOCAL-AGENCY I]STATE-AGENCY <br /> ]CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME I STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4_74 - ;Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box bMkM (] 1 SELF-INSURED O 2 GUARANTEE ] SIN WFAANCE Q L SUREtt EOND <br /> ]5 LETTEROFCREGT ]a EXEMPTION 73,96THER <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 BILLNG: C;2�_ IL❑ IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> /e-zv l <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION It FACILITY# <br /> W 1vIM4U760 77� a0 2 <br /> LOCATION CODE -OPT/O AL (CENSUS TRACTS -�O9PrONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ,ba <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 9,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORaOpA.S <br /> 1 <br />