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PQ6OUR fg C <br /> STATE OF CALIFORNIA `1 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4�0.�; <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED S <br /> :�n <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O AC ITY NAME NAMq OF OPERATOR <br /> C 0 • a.pi <br /> ADDRESSNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3,Z/2,, . Ca c. o✓n1c: ,ki e_ <br /> CITY NAMESTATE ZIP CODE SITE PHONE#WITH AREA CODE bD <br /> CA S 4-I - <br /> ✓ BOX <br /> TOINDICATE CORPORATIONDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR I/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: AME(LA T,FI ST) PHONE#WITH AREA CODE DAYS: NAME(LA T,FIRST) goo—�. -9 j(rj <br /> V0 . a i p ' 4I--x?6 q Cv ('PI le J4 �e T � <br /> NIGHTS: NANE(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Sam e. Sa m>z PHONE#WITH AREA COD <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> � ao - l C �'PI v vita .ea S e. <br /> MAILING OR STREET ADDRESS I ✓ box icate INDIVIDUAL = LOCAL-AGENCY = STATE- GENCY <br /> P. ORPORATION 0 PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> r-4!&iC' o oa-6o3 7, -6 ©o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD RES ✓ box t icate = INDIVIDUAL LOCAL-AGENCY E ST E-AGEN <br /> • (� S Q- 01>tw 3 CORPORATION = PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY N M STATE ZIP CODE PHONE#WITH AREA CODE <br /> r 2 t ' o o2-6v3g -SIDS <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 F41-1 e) <br /> V. PETROLEUM UST FINANCIAL,RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate Et� 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[_7 II.0 III. <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) APPLICANT'S TITLE DATE M NTH/DAV EAR <br /> a �'. �S,` 8 Z2. ja <br /> LOCAL AGENCY USE ON <br /> COUNTY# JURISDICTION# FAC ILLIITYYY# <br /> LOCATIO CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> � Z3 <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 /> FO RM A(5-91) �pFOR0033A-5 <br /> �� x'123 gj i�/� I <br />