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r i • e�ouN � <br /> STATE OF CALIFORNIA W mss. <br /> STATE WATER RESOURCES CONTROL BOARD `P. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A W�� '�° <br /> 1 . <br /> ��II.ONN�N <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLYC S ITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAORFACILITY NAME NAM OFOPERATOR <br /> 1 oak <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OFTIONAu <br /> 33<•E E. 1-taL� 5�-- <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Ca 23I/ BOX <br /> r2i <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP Ij LOCAL-AGENCY O COUNTY AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION ^ � <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS LCL 00002 L 7' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FI T) <br /> aA k s '( ao 17 - Sy 9 - L313 OWLS tF>1 PHONE#WITH AREA rnnP <br /> NIGHTS: NAM (LAST,FIRST) PoHONE#WITH AREA CODE NIGHTS: NA (LAST,FIRST) Y7 O 7� A -to 'p — <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME C(`11• 4� CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREETADORESS ✓ boxbindiaale INDIVIDUAL O LOCAL-AGENCY Q STATE AGENCY <br /> - 0• a 'TLFOp [�]CORPORATION E::] PARTNERSHIP l=COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME //�� STATE ZIP CODE PHONE#WITH AREA CODE <br /> L45 CJ C5 0- A, qo o S4 <br /> III. TANK OWNER I ORMATION-(MUST BE COMPLETED) <br /> NAME OFIA."'O� VSA �� uL a— CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREET ADDRESS ✓ box b Indicate = INDIVIDUAL l� LOCAL-AGENCY E-71STATE-AGENCY <br /> _ YV J00 CORPORATION l= PARTNERSHIP Ej COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME !� STATE ZIP CODE PHONE#WITH AREA CODE p <br /> 14' S(0 — 8q 2- - ZSOO <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -1017-111 Ill 15, <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlbate 1 SELF.INSURED L�]2 GUARANTEE E= 3 INSURANCE 4 SURETY BOND <br /> 5 IETTEROFCREDIT =6 EXEMPTION O W 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD WED FOR LEGAL NOTIFICATIONS AND BILLING: i.P�l 11.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UN PENA Y RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> 17 <br /> APPLICANT'S NAME(PRINTED&SIG ATURE) APPLICANTS TITLE t DATE MONTWDAYNEAR <br /> Dkw IO .5tA(& <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# (-+C}LV C `?j 5 <br /> mp 6 (P 5 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -.OPTIONAL <br /> 2- 0- 92 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANG R FORMATIO ONLY. <br /> FORM A(5.91) LFO A5 <br />