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I STATEOFCAUFORMA <br /> STATE WATER RESOURCES CONTROL BOARD �D$ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> W� r <br /> .o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> �3 `' ) <br /> 0`5�(t <br /> MARK ONLY O I NEW PERMIT O 3 RENEWAL PERMIT `6 <br /> ONE REM Q 2 INTERIM PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CL <br /> Q t AMENDED PERMIT g TEMPORARY SITE CLOSURE <br /> I. FACILFTY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB R FACIL NAM <br /> f NAME OF 7)i:1 <br /> ADDRESS (� C 'L/lON h n O <br /> ' N RE ' <br /> /STCROSSSTI `l, PARCEL#(OPIONAL) <br /> STATE CITY NAM <br /> 21P <br /> 1t TCTY L S PHONEx WITH AREA CODE <br /> ✓ BOX CA s o20 �7- <br /> TOINdCaTE O CORPORATION Q INDIVIDUAL p PARTNOS14P Q LOCAL-AGENCY <br /> 'N a er of UST la a public agency. DISTRICTS' "1GEPoy' 1 STATE-AGENCY' <br /> 1 ag ty,meplefe he runisd SUPWisor of d"Ion.eeoUon,or office which FEDERAL#GENCY' <br /> aperatex the U37 <br /> j TYPE OF BUSINESS a 1 GAS STATION O 2 Di 3LJTORIF INDIAN x OF TANKS AT SITE E.P.A, I.D.x(qw",/) <br /> f( 3 FARM Q s PROCESSOR = 5 OTHER OOR RE-/SRVATION <br /> I <br /> I EMERGENCY CONTACT PERSON (PRIMARY) <br /> e DAYS: NAME( <br /> LAST,FIRST) EMERGENCY CONTACT PERSON (SECONDARY) <br /> ITHAREAC <br /> PHONE x WITH AREA CODE <br /> NIGHTS: NAM (LAFIRST)� NLTEx WITH AREA 9P <br /> L D (}�.O44a N GHTS: NAME(LAST,FIRST) PHONE x WITH AREACODE <br /> 11. PROPERTY OWNER INFORMATION- UST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> I' MAILING OR STREET ADDR <br /> D 0 Q ✓ boa In Indra s NDIV DUAL ILOCAL-AGENCY 0 STATE AGENCY <br /> CITY NgME r ED CORPORATION C:3 PARTNERSHIP ED COUNTY-AGENCY <br />. � CST ZIP CODE O FIDFIML-AGENCY <br /> TO z:;i G> D^- PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) O/ <br /> NAME OF OWNEq <br /> f'�p,N� a GAJ TCAREDDRESS IMAILING OR STREETADDRESS / ezINDIVIDUALO LOCA4AGENCY STAIEAGENCY <br /> Cf TV NAME MTION O PARTNERSHIP EDCOUNTYAGENCY � FEoEgAL- ,,,,ZIP CODE PHONEx WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(91 6)322-9669 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY.(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bW blMlkale O 1 SELF,__ L_j 2 GUARANTEE Q 31 NSUgANCE <br /> O 5 LETrEROFCFEW a EXEMPTION W OTHER /IJ /)J� O A 7! BONG <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 BILLING: <br /> 1.0 II- IILEj <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE <br /> DATE MONTHIDAVNEAR <br /> LOCAL AGENCY USE ONLY A] <br /> COUNTY x JURISDICTION s <br /> ® FACILrrY• <br /> EnO7 -OPTIONAL 3, T. SLNNISDq.DISTRICT DDDE - <br /> PIC L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,INLESS THIS IS A CHANGE OF SITE I FOpMATION ONLY. <br /> FORM A(383) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKINS <br /> - -- ,5-a/-/- 9-,/ LM <br />