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i <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 34�, <br /> �UNDERGROUND <br /> STORAGE TANK PERMIT APPLICATION - FORM A w yo <br /> n <br /> °4 oon <br /> COMPLETE THIS FORM FOR EACH FACILfTY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:j 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM NAMEOFOPERATTOR � <br /> L!H 7$ O p 60117114;1-) ©1111/ l/^C-> <br /> ADDRESS _ NEAREST CROSS STREET PARCEL a(OPTIONAL) <br /> 1/.37 e, I"41*2ti- <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S7An CAv BOX <br /> TO INDICATE CORPOfl ION Q INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY OUNTY-AGENCY 0 STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSE:jj�l GAS STATION Q 2 DISTRIBUTORQ ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.a(gwima# <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) , _ qY -21 <br /> GGI <aJP - � 11/i -9yf- -2 -76 ,-/Glie Alva <br /> NIGHTS: NAME(LAST,FIRST) 4-41 a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA GOOF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> uNo cfJ/< <br /> MAILING OR STflR ET ADDRESS ✓ boabin0bab C:2 INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE21P CODE PHONE x WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNe, E, �ock N CARE OF ADDRES�INFORMj'E' �6 <br /> MAILING OR STTREETADORESS ✓ bmbimKam Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Pr Q 4 Sox / 0 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATEPHONE M WITH AREA CODE <br /> Sun '7'E/_5_f3 <br /> IP CODESf3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call 1916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - p 3 3 a (d <br /> V. PETROLEUM UST FINANCIA PONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boa birAicau 1 SELFFINSURED O Y GUARANTEE 3INSURANCE 0 a SURETY BOND <br /> = 5 LETTEROFCREDIT 0 6 EXEMPTION Q 93 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: L= II.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1�41 7 107,yq <br /> LOCATION CODE OPTIONAL (CENSUS TRAM OP77ONAL 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 srTE INFORMATION ONLY. <br /> FORM A(5.91) FOR0033A5 <br /> 0 ! � 1�7/�\ p <br />