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0 0 ao . o <br /> STATE OF CALIFORNIA �' s <br /> STATE WATER RESOURCES CONTROL BOARD q�, o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> O YI.. <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 3 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION7 PERMANENT SED SITE <br /> ONE ITEM 2 INTERIM PERMIT i0 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE rJ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITYNAME NAMEOPERATOR �� <br /> Arc, vn�Javid Z[Alrl,y Kobet <br /> Kobe-v'-It- <br /> ADDRESS NEA EST CROSS STREET PARCEL#(OPfgNAq <br /> Illi 5 . TL) Ike, nnevc� W�� fb -D5 <br /> CITY NAME STATE ZIP CODESITE PHONE#WITH AR CODE <br /> S ("bG ✓1 CA ZD� a0q �63^ ��s <br /> ✓ BOX <br /> TOINDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERAL AGENCY <br /> OSTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN ja OF TANKS AT SITE E.P.A. I.D.9(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 0 5 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) <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> WITH APPA Qn--�:] <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 1).{+ -F- GGA C• �� t-e—✓ <br /> MAILING OR STREET ADDRESS �(' I '/ wxbintlbau Q INDVIOUAL Q LOCAUAGENCY QSTATE-AGENCY <br /> k-•3- t t S. I L)r� t L� [+ICORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE ar WITH AREA CODE <br /> S'bc.k+W-1 L t5z a� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAMEOFOCARED ADDRESS INFORM ION <br /> NER <br /> c. PLJvvx -r vsel� t Lit lei <br /> MAILING OR STREET ADDRESST �(Q �✓ wx bitbb40 Q INDIVIDUAL Q LOCAL.AGENCY Q STATE-AGENCY <br /> INCORPORATION Q PARTNERSHIP Q OOUNIY.AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATF - ZIP a <br /> COf�j '5 PHONE WITH AgEA CODE <br /> (/�Y�p1. -j lJ q1/ 2 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4-T74 - <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 10 n&ro Q I SELINNSURED Q 2 GUARANTEE i0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETrEROFCREOIT Q 6 EXEMPTON Q W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 it. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYOF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRNTEO&SIGNATUREAPPLICANTS TITLE DATE MONTWDAYNEAR <br /> gm <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY it <br /> ® I I It 8 <br /> LOCATIONCODE -OPTIDNAk CENSUSTRACT# -OPT/ONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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) (►�J ,//� <br /> 0 f`•C?u y � •1 / '/// Fg16077I( <br />