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L7 375/ <br /> STATE OFCALIPoRWA <br /> STATE WATER RESOURCES CONTROL BOARD + ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH F RYISITE <br /> MARK ONLY O t NEW PERMIT E:] 3 RENEWAL PERMIT HANGE OF INFORMATION lr PERMANENTLY CLOS ITE <br /> ONE REM Q 2 INTERIM PERMIT E::] 4 AMENDED PERMIT O e TEMPORARY SITE CLOSURE �3 <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DSAO Wg JC AME NAME OF OPERATOR <br /> tl/fJ,C'O/� (.I/ EGfiIEKS �/1Ffi�L. SA/r/,rjZYi/tL <br /> ADDRESSL�� NEAREST CROSS STREET PARCEL#(OPTONAp <br /> / <br /> A -1 L04145�E <br /> CITY NAME / 7� STATE A ZIP CODE � SITE PHONE#WITH AREA COI/ BoxDE <br /> 959 <br /> T NOICRTE O CORPORATION Mf INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCY' Q FEDERAL-AGENCY' <br /> If Amer of UST Is a public agency. DISTRICTS' <br /> D B cl'.complete the following:name d Supervisor d tlielabn,section,or dlim which operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.O.i(Optional) <br /> Q 3 FARM 4 PROCESSOR [�5 OTHER <br /> OORTRUSTVATION <br /> LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �I AU9G fiYicL S�/ Ar aUgL F ZOq 8 5�1;4 <br /> NIGS: NAME(LAST.FIR T) PHONE#WITH AR E NK6ITTS: NAME ,FIRST) PHONE#WITH AREA CODE <br /> IJvc L ,crY�L ^O j off/ <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME. CARE OF ADDRESS INFORMATION <br /> `RGL FR�tvrg5 , 44,Pvv,+L <br /> MAILING/OR STrR T/ADDR/EySS /� ✓ �x bin6lraN NDIVIDUAL O LOCA4AGENCY �STATE-AGENCY <br /> �F7� 7 27 /z_-1/vz,e5, O CORPORATION O PARTNERSHIP 0 OOUNfY-AGENCY =) FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> G/"Rb�p 44, f,'k-330 <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER. CARE OF ADDRESS INFORMATION <br /> �AF��G �ti�5 �an�oa�L <br /> MAILII ORSTREET ADDRESS ✓too bN6leAMINDIVIDUAL O LOCAL-AGENCY 1� STATE-AGENCY <br /> d ✓r s AfteiNLEy �'d� �CORPORATION 0 PARTNERSHIP 0 COUMY.AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STA21P CODE3� PHONE#WITH AREA C09� <br /> Z/�TNR L !; <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4-1- Q y <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box btdkate = 1 SELFINSURED L—I 2 GUARANTEE El 3 INSURANCE 4 SURETYBOND <br /> lJ 5 LETTEROFCREDT 0 6 EXEMPTION [LIo-9117—OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.D III.[� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PflINTE08 SIGNED) OW EATS TITLE DATEd MONTHIDAYIY'EAR <br /> �67TiF,Ai Free dAFitb L aoXtiRG �'7,S' <br /> LOCAL AGENCY USE ONLY a Y 6 <br /> COUNTY# JURISDICTION a FACILITY• <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT I -OPTIONAL SUPVISOR-DISTRICT CODE -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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) FOflOm3Afl7 <br />