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d • • dyoV•cc9 <br /> STATE OF CALIFORNIAco <br /> STATE WATER RESOURCES CONTROL BOARD ey a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSES <br /> ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE.COMPLETED) <br /> D AORFACILITVNAME NAM OFOP RATOR <br /> mcx�nt�— <br /> V � K <br /> /�s^/ y� NE STCROSSS�R�EEEETT PARCEL*(OPTIONAL) <br /> DORESME _ GAG <br /> \ 7 STATE ZIP DE SITE PHONE+e WITH AREA CODCA s -7 <br /> -71 <br /> To <br /> I/ Box <br /> xTE CORPORATION INDIVIDUAL �PAIITNERSNIP-_ 0 D <br /> LOCAL-AGENCY <br /> AL-AGNCY. 'Q COUNTY-AGENCY O sTATE-AGENCY FEDERAL-AGENCY <br /> TRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR RESEgyATD Is OF TANKS AT SITE E.P.A. I.D.#(optbnal) <br /> O 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON IS <br /> •optional <br /> DAY ' NAME(L T.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> az- S <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH A A CODE NIGHTS: NAME(LAST,FIRST) <br /> . PROPERTY OWNER INFORMATION•JMUST BE COMP ETED <br /> NAME �O A I CA E OF ADDRESS INFORMATION <br /> MAILING OR STREET AD �2E4 / �CA boa buNkau Q INDIVIDUAL � LOCAL-AGENCY O STATE'AGENCY <br /> 1Y A aey'K C CORPORATION �L PARTNERSHIP COUNTY�AGENCY FEDERAL AGENCY <br /> CITY NAME %A- lJ� ��� ATEG� ZIP CODE��� PHONE#WITH AREA CODE <br /> \N`V III. TANK 0 ll0 $E F1 FO {T6 7 <br /> NAME OF OWNER CPRE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa biWiCau D INDIVIDUAL Q LOCAL-AGENCY 0 STATE AGENCY <br /> CORPORATION O PARTNERSHIP COUNrY#GENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HO 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ wx biAKau 0 I SELF INSURED =2 GUARANTEE (] 3 INSURANCE a SURETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION O 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: IME& IL III. <br /> 7 <br /> THIS FORM HAS SEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8SIG AT REI APPLICTS TITLE DATE MO TWOAV/VEAR <br /> LOCAL AGEN&USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> C—LJ=1� <br /> 3.9 ,—.-�-- <br /> F <br /> LOCATION COD OPTIONAL !CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT E 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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS fy FOADM31 <br />