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• • • • eeb°°a e c <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD +,; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A 3n <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED STE <br /> F� <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OF OPERATOR SAME <br /> r-AyV w NEARESTCROSS STREET PAACELN(OWIONAW <br /> ADDRESS x e"�' e r r <br /> Z 44 q E. IIY�IBX N � it E r l� P C <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> (_k-% + ca 9.� v N E <br /> ✓ BOX L�7 COgPoRATION INDIVIDUAL PARTNERSHIP I� LOCAL-AGENCY 0 COUNTY-AGENCY �STATE-AGENCY � FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> ✓ IF INDIAN z OF TANKS AT SITE E.P.A. I.D.#(OPUMI10 <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR RESERVATION <br /> ❑ 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 a WITH AREA CODE =FIRST) � eJ4 12,. S(O9,s`WAr , 1.aan rTNIGHTS: NAME(LAS FIRST1) PHONE#WITH AREA CODE CNc_� Ojj'TS �E <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> C R/"x hN �� NR+^AA`W box bindcab IOI INDIVIDUAL Q LGCALAGENCY IN STATE-AGENCY <br /> MAILING OR STREET ADDRESS J�^�' <br /> CORPORATION O PARTNERSHIP l�COUNfV-AGENCY FEOERALdGENCV <br /> CIN NAME !•� STATE ZIP CODE PHONE WITHAREACODE <br /> CA 5 v! y(o- 2200 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> MAILING OF':STREET ADDRESS �✓/box billdicale Q INDIVIDUAL 0 CLOCAL-AGENCY [�STATE-AGENCY <br /> 1"G q [ COgPoRATION O PARTNERSHIP I� COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME 1S A `7 STATE ZIP CODE P ONE WITH AREA CODE <br /> SAN) �A+A`�^r Ca GySf�3-v{�o Slt By2- (a9s' <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ �4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> 1 SELF INSURED ❑2 GUARANTEE D 3 INSURANCE 4 SURETY BOND <br /> ✓ box bindicale U 5 LETTER OF CREDIT =6 EXEMPTION I-1 W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ IL❑ III.LIP— <br /> THIS <br /> JTHIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APCCANT'B NSE IP T &SIGNATURE) AIE@s0 APPLICANTS TITLE I. DATE MONTWDAV/YEAR <br /> oo--✓✓ N '.t �re tEMNv 8- <br /> 23- 910 <br /> APLL � a&,N. N •�R.Act:.rJ �Qojlc7 y._ <br /> LOCAL AGENCY USE ONLY c ~ <br /> COUNTY# JURISDI TIN# <br /> -- CENSUS TRACT -OPTIONAL - � <br /> LOCATIONCODE -OPTIONAL SUPVISOR-DISTRICTC -`-BF1:I6NdL--'--"-'` <br /> © OOb <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 /> PORMA(12.91) FILE THIS FORMWITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A R6 <br /> 0 R,-3w6 <br />