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` ♦E6ouR�n. CpLi <br /> r. STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� �e <br /> � , o <br /> 1 � OPN�� <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME , .1/�� NAM OF OP RATOR <br /> 1 A/ <br /> ADDRESS NE ST CROSS S REET PARCEL#(OPTIONAL) <br /> 4-4-O . Main S u <br /> CITY NAME / k1 N C o STACA ZIP�C DE SITE PHONEx WIT=AREA LADE <br /> /tj <br /> 7 16 <br /> TOINDIICCATE —1 CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRI <br /> TS <br /> TYPE OF BUSINESS 1 GAS STATION = 2 DISTRIBUTOR O ✓ IF INDIAN x OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DANAME(L T,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 1z a, i z S ao - />o <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH A5EA CODE NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMP ETED <br /> NAME (P CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD ESS 2 ✓hoabindkau 0 INDIVIDUAL O LOCAL 0 STATE-AGENCY <br /> S3 +- ahC�.'k 5'f 3 0 CORPORATION X PARTNERSHIP 0 COUNTY-AGENCY FEDEMLAGENCY <br /> CIN NAME I '^ ST;7 ZIP CO�572 PHONE x WITH6 AREA C��/ <br /> III. TANK 0 ER INFORMATIONN-'((M{{UST BE COMPLETED) /T <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ INDIVIDUAL LOCAL AGENCY L_ STATE-AGENCY <br /> I=CORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST T RAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box ooftMa n 1 SELF INSURED E::]2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETrEROFCREDn E_] 6 EXEMPTION CJ 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. I.[�] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 51 T RE) APPLIC TS TITLE DATE/ M TH/DAYNEAR <br /> (� 0 712,3 <br /> LOCAL AGENd USE ONLY <br /> COUNTY it JURISDICTTIO�INI # FACILITY <br /> /# <br /> I1'L LSA I-1--��L-ld_'�2—LJ <br /> L-- ___— <br /> C E <br /> LOCATION COD _OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT 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(12-9n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULA(T�IONS <br /> W-1 - / 3�^� � fl0095 <br />