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STATE OF CALIFORNIA <br /> RTATF WATER RESOURCES CONTROL RK!AR.D <br /> Cob <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FUHM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY _] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY Cra <br /> TE <br /> ONE ITEM U 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> _ A-�� SZr�T d � <br /> ADDRESS REST C STREET PARCEL N(OPfIONAL) <br /> CITY NAME STACA Z} CO�f/ SISE P�NE x WITH AREA CODE <br /> ��4d_ <br /> --✓Box <br /> TO INDICATE CORPO ATION Q INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBU O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY C SON (PRIMARY) \ EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAS )I PHONE A A CODE YS: NAME(LAST,FIRST) <br /> S�✓ V•� �'�, (�VN.L! PHONF ft WIT <br /> NIG NAM AST.FIRST) PHONE#WITH AREA CODE NIGHT NAME(LAST,FIRST) PHONE#WITH AREA C <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADD SS INFORMATION <br /> MAILING OR STVT ADDRESS ✓ box bindcaleINDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 d E-1 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME —1-- ���I- STATE,_ ZIP OD_710 HONE Ji WITH AREA CODE <br /> /�f�� /VJ '7" 117_ v -7-4, <br /> III. TANK OWNER INFORMATION:,(MUST BE COMPLETED) <br /> ME OF OWNER uavlv CARE OF ADDRES INFORMATION <br /> "�& <br /> - <br /> MAIL GOR STREET ADDRESS. ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY <br /> (]STATE-AGENCY <br /> 0 CORPORAT N 0 PARTNERSHIP 0 COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NA f STATE ZIP CODE PHONE M WITH AREA CODE <br /> -I- c P 702-60' -46 <br /> IV. BOARD F EQUALIZATION��T S�A�E FEE ACCOUNT NUMBE Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 -C (� <br /> V. PETROLEUM UST FIN RESPONSIBILITY,( TBE COMPLETED)—IDENTIFY THE OD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE URANCE I_j 4 SU ND <br /> 5 LETTER OF CREDIT L� 6 EXEMPTION L--1 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11/' checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.F] II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CO RECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEW <br /> �3 <br /> LOCAL AGENCY USE ONLY (� <br /> COUNTY s �I7 � 7 JURISDICTION t; �F�AC�ITY#1 <br /> LOCATION COD OPTIONAL CENSUS TRACT u -OPTIONAL SUPVISOR-DI TRICT CODE -OPTIONAL <br /> 7-160 2� <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 /> /� FOR0033A R6 <br />