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P�s,J:nG�S <br /> STATE OF CALIFORNIA °- <br /> STATE WATER RESOURCES CONTROL BOARD <br /> 3 <br /> -�,� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM, A <br /> .:p <br /> c, <br /> COMPLETE THIS FORM FOR EACH FACILITY;SITE <br /> MARK ONLY _Y' 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> CNE ITEM 2 NTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITYSITE INFORMATION & ADDRESS- (MUST BE COMPLETED) <br /> DBA OR FACILITY NAME I Do NAME OF OPERATOR <br /> i GOAfvo I <br /> ADDRESS NEAREST CROSS STREET PARCEL tt(OPTIONAL) <br /> 7is`7 S 570 <br /> CITY NAME STATE ZIP dom SITE PHONE x WITH AREA CODE <br /> CA d _/7 <br /> ✓ Box <br /> TO INDICATE CORPORATION INDIVIDUAL C PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION2 DISTRIBUTOR _I '/ 'FIND AN <br /> FINDAN x CF TANKS AT SITE E.P.A. I.D.x(optional) <br /> O I! RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSCN,JSECONDARY)•optional <br /> j DAYS: NAME;LAST,FIRST) A PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> _�3 = 5 , 249 3��- -AREA r 7 <br /> NIGHTS: NAME(LAST,FIRS 'f x WITH AREA CODE NIGHTS: NAME( FIRST) <br /> PwONE tt WITIH AREA Cnn,: <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETE <br /> NAME � / � _ � CARE OF ADDRESS INFORMATION <br /> MAILI OR STREET ADDRESS ✓ bo Nki1B 0 INDIVIDUAL C LOCAL-AGENCY STATE-AGENCY <br /> S' 2 L_X�J/ RPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAn F � ATE -I/"11_ ZIP CODE 14 � P / __ H AREAU�D�� v v <br /> I /✓ �i <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER '�/�w CARE OF ADDRESS INFORMATION <br /> n� <br /> MAI NG OR STREET ADDRESS ✓ box to indicate INDIVIDUAL U LOCAL AGENCY 0 STATE-AGENCY <br /> L t 6 / Q CORPORATION C PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY AME STATE ZIP CODE PHONE x WITH AREA CODE <br /> �IZTCS P-70 // 0 — �IJ7—2-6 U <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call (916)323-9555 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> _ 1 SELF-INSURED 2 GUARANTEE <br /> ✓ box ro indicate — �� 9 IN/SUggNCE i 4 SURETY BOND <br /> 5 LETTER OF CREDIT 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 /> HECK ONE BOX IN WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.i' III. <br /> � ` <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTHYDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 31c�] =C 10 ( "] n� <br /> L'UCATION CODE -OPTIONAL CENSUS TRACT x -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 /> FORM A(5-911 FOR003A 5 <br /> �l <br />