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• STATE OF CALIFORNIA • I�/� ` �r n e� c'� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> C�I�nO�M� <br /> COMPLETE THIS FORM FOREACH ISITE <br /> MARK ONLY 1 NEW PERMIT n 3 RENEWAL PERMIT [G 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILIT�'NAb NAME OF OPERATOR <br /> C� I -- <br /> ADDRESS <br /> --ADDRESS t` NEAREST CROSS STREET PARCELS(OPTIONAL) <br /> U!D F. 112ao <br /> CITY NAME ` � // STACA ZIP CODE � SIT PHOl #WITH AREA <br /> _ IE��V��7,/ <br /> TO <br /> "Of <br /> TO INDICATE O CORPORATION D INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY O COUNTY AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRITS <br /> TYPE OF BUSINESS O I GAS STATION 0 2 DI$TflIBOTDR / q SERVATIO <br /> D AN p OF TANKE E.P.A. L D.#(opfimap <br /> O 3 FARM Q 4 PROCESSOR [_ /5 OTHER OR TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH A A CO E IGHTS: NAME(LAST.FIRST) <br /> PHONF#WITH AREA CODEII. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME �< Of CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bit 0 INDIVIDUAL 0 LOCAL-AGENCY E-1 STATE-AGENCY <br /> O Q Q'O Q CORPORATION Q PARTNERSHIP [:DCOUNTY-AGENCYEDFEDERAL-AGENCYCITY NAME , STATE ZIP CODE PHONE#WITH AREA CODE <br /> c Cc/ 9SZo2 201 -9yy-8a�i <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box 010icale 0 INDIVIDUAL 0 LOCAL-AGENCY L�j STATE AGENCY <br /> Q CORPORATION E-1 PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD 0 ALIZATION UST STORA FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biiMicale n I SELF INSURED [�j 2 GUARANTEE 3INSURANCE Q 4 SURETY BUND <br /> 5 LETTEROFCREDIT 0 6 EXEMPTION 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.E II.0 ILL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY C� <br /> COUNTY# JURISDICTION III, FACILITY# L 5.1611✓ 10 <br /> 3 q TTJ 23 939 <br /> LOCATION CODE OPT/NAL 'CENSUS TRRACT# -OPTIONAL SUPVIS02 DISTRICT COE -OPTIONAL <br /> ;1_51vo 32-3 <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(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033AR6 <br />