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l� <br /> e.o . e . <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD n` ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> s , o' <br /> �41rOn NDN <br /> COMPLETE THIS FORM FOR EAC CILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE L <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME _ NAME OF OPERATOR <br /> V4cN'1t Sc J d- IhAuc.4-r-c—k A4 p p Z'clk - � cei4r — <br /> ADDRESS ` c NEAREST CROSS STREET PARCEL (OPFIONAL) <br /> 1 PJ ` r A^-c4 (r S <br /> CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE <br /> Sd-0 CA <br /> ✓ BOX <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL O PARTNERSHIP [=1 LOISTL-AGENCY =1COURTYAGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> RICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN 11OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> O 3 FARM 4 PROCESSOR = 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 /> � <br /> vuce� �e <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WIT AR CODE NIGHTS: NAME(LAST,FIRST) <br /> I — PHONE It WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> boLA cef--k ( 7'vh n c!- V era <br /> MAILING OR STREET ADDRESS ✓ box b Indicate Q INDIVIDUAL Q LOCAL-AGENCY (]STATE AGENCY <br /> T <br /> 7 3 L(a— 14 A r O CORPORATION = PARTNERSHIP E-1 COUNrY-AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 'y�ck4-vh CA 'n-go-s— ZU9- - 3=r— <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box0 wicale E71 INDIVIDUAL LOCAL-AGENCY L_j STATE-AGENCY <br /> 0 CORPORATION I= PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD QU ON US STORAGE FE COUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) H L4 4 <br /> V. PETROLEUM SIBILITY-(MUSTBECOMPLETED)-IDENTIFYTHEMETHOD ) USED <br /> ✓ box bindicate I SELFINSURED [71 2 GUARANTEE D 3 ANCE 4 SURETY BOND <br /> 1 5 LETrEROFCREDIT L= 6 EXEMPTION 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 check <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ I. III.❑ <br /> THJS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIVEAR <br /> LOCAL AGENCY USE ONLY `7 <br /> COUNTY# JURISDICTION# FACILITY If <br /> 3; LJ FT1 I L. <br /> LOCATIONCODE^0%OPTIONAL ICENSUSTR <br /> RACT# -OPTIONAL SUPVISO -DISTRICT <br /> , -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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0039AP6 <br /> 0 46 <br />