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y _ - ---_- IABD ; <br /> IV1J -Ij PLICATION- FORM A <br /> Y/SITE <br /> LMARK y E OF INFORMATION 0 7 <br /> ONE A E LOBED <br /> RARY SITE CLOSURE S <br /> I. FACII a IL �lown <br /> If <br /> ____ - - —_ 1 (,'1=, <br /> OR <br /> �L✓JL r <br /> � ' <br /> — — _ <br /> STfE I lA(OPfKINpt) <br /> ('/1.-(Gt.�l►{(�// _ �nLti/✓OA`U�PYnI <br /> SITE PHO e W AREA CO <br /> - - Z�3 <br /> ✓ E( - 3 - <br /> TOINDIC' - -- 1 COUNTY-AGENCY' <br /> 'IT mnerdi 0 STATE-AGENCY' El FEDERAL-AGENCY' <br /> tog the UST <br /> - <br /> J ,DIAN a OF T5 AT SITE E.P.A. L D.a(gelAnaq <br /> TION <br /> AN <br /> ANDS <br /> DAYS: NAA <br /> IRGENCYCONTACT PERSON (SECONDARY)-optional <br /> / ST.FIRST) PHONE;I WITH AREA CODE <br /> NIGHTS: ! fl'/W,A'//�� - C� LAST.FIRST) <br /> PHONE;F WITH AREA CODE <br /> II. PRO-- - <br /> NAME --- <br /> � ��,/ Q SS INFORMATK)N <br /> MAILING 0 —'-r'-✓- -� .. <br /> INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> V O PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> -—IP CODE PHONE t WITH AREA CODE <br /> III. TAI __- <br /> NAME OF <br /> - iSS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ oe binEbAle <br /> O INDIVIDUAL 0 LOCA4AGE1ICY ESTATE-AGENCY <br /> b <br /> CITY NAME O CORPORATION PARTNERSHIP O COUNTYAGENCY Q FEDERALAGENCY <br /> STATE ZIP CODE PHONEx WITH AREA CODE <br /> IV-80 !DOF EQUALIZATION UST SWTO/RnA�uIm FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-K- <br /> V. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxbintlkafe 0 1SELF-INSURED Q p GUARANTEE O E INSURANCE <br /> 0 5 LETTEROFCREDIT O-EXEMPTION (]99 OTHER O A SURETYBOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless x I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I- II.E] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED S SIGNED) OWNER'S TITLE <br /> DATE MONTH/DAVIYEAq <br /> LOCAL AGENCY USE ONLY <br /> COU,�,NTYq JURISDICTION y�S �=OP770 <br /> ALJ�IIJILOCATK)NCODE - TIONAL CENSUSTRACTS -OPTIONAL3•,Q/- aUPVIaOR-DISTRICT COD <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(m) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND <br /> STOR� E T] REGU .T'Y FpiW31fl7F 0Z / TCS <br />