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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD `ow <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A vle <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE �7 <br /> MARK ONLY I NEW PERMIT j 9 RENEWAL PERMIT 5 CHANGE OF INFORMATION El T PERMANENTLY CLO �$ITF <br /> ONE ITEM 2 INTERIM PERMIT r' A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> NAMEOFOPEAMOR <br /> JBA/O�R FMAC:L/I i/NAME) <br /> ADDRESS I NEAREST CROSS STREET PARCELS(OPTIONAU <br /> 6(J0 - AAktLajJ VC'' <br /> C:TY NAME STATE LP COLE i SITE PHONE A WITH AREA CODE <br /> Gh��vq GIA11 BOX <br /> . 4536 Ca <br /> TOINGCATE Q CORPORATION Q INDNIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTYAGENCY Q STATE AGENCY IQ FEDERALAGEWY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. L D.6(MN ) <br /> RESERVATION <br /> u. 3 FARM A PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optioral <br /> LAYS: NAME;LAST,FIRST) _ PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) Z rj 1— `f 3- <br /> T�. T a0 �� 10(' I <br /> NIGHTS: NAME( .FI ST) PHONE a WITH AREA CODE NIGHTS: NAME(LASEtR81) <br /> ^ �o �- ��3 9zSi �� - 2c9•�a�-AfLu <br /> I. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> E CARE OF ADDRESS INFORMATION <br /> kA R C uav 7-- <br /> MAILING OR STREET ADDRESS <br /> - <br /> MAILINGORSTREETADDRESS .c ✓ Ou bimicau Q INOMDUAL Q LOCAL-AGENCY Q sTATE.AGENCY <br /> CORPORATION Q PARTNERSNP Q COUNTY-AGENCY IQ FEDERALAGENCY <br /> CITU NA /� J� STATE ZIP CODE PHONE s WITH AREA CODE <br /> 144N�� -4 , <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> .NAME CF OWNER I CARE OF ADDRESS NFORMATION <br /> MAILING OR STREET ADDRESS ✓ W.bYb. Q INDIVIDUAL Q LOCAL AGENCY Q STATE AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY.IGENGY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP COLE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> ( TY(TK) HQ F47- <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J 5At Din6eAM I SELF-INSURE) Q 2 GUARAMEE Q 3 INSURANCE Q L suaiiY BONG <br /> 0 5 LETTER OFCREMT Q 6 EXEMPTION Q W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or IL is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.d 11.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLCANT'S NAME(PRINTED B SIGNATURE) - APPLICANTS TITLE DATE MONTPJOAY•NEAR <br /> 4LIAA S./ /LOY79 — f �fy}�eLTSv Uil y2� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION N FACILITY n <br /> -rWYI I <br /> LOCATION COCE -OPTIONAL (CENSUS TRACT -OPTIONAL SUPVISOR-OISTR$CT CODE -OPTIO L - <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-911 FOR=3A5 <br /> dr-0 mwl I-�i��11 y1v <br />