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*_ _ <br /> STATE OF CALIFORNIA �� t• �� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A zta <br /> :. ,.' o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT U 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT J 4 AMENDED PERMIT C 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY 6� <br /> N E NAME OF OPERAIR <br /> ADDRESS Y(2cs� STA'fionts � rvC . <br /> NEAREST CR�ApSS STREET PARCEL s(OPTIONAL) <br /> CITY NAME I STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> \\\PsNT2Cn <br /> sox CA �tS33-� 2-2.� 40120 5 <br /> ✓ <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSWP Q LOCAL-AGENCY a COUNTY-AGENCY <br /> STATE-AGENCY FEDERALa1GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I. <br /> � D.s/opbmall <br /> 7 FARM � 4 PROCESSOR RESERVATION <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NA�M,rE�(LAST.FIRST) PHONE WITH AREA CODE <br /> DAYS: NAME(LAST FIRST) \ <br /> ( Sb2� qU2- "Lbs XRCo 7�A��lennCvn c a cmo 1 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAkT.FIRST) PHnNc <br /> m(sa. oN 4x2. 1205 (gUo12�z_(,3a`i <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> loco �c Cv t✓�4 Y, S <br /> MAILING OR STREET ADDRESS box ID w4ca INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> v - �00 ORPAION PARTNERSHIP COUTY-AGECY <br /> FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEWITH AREA COO <br /> aN `� cam. Gd�o �cs3g (-)ky �0-)0-sIC� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFO RM4710N <br /> ES S N _ <br /> MAILING OR STREET ADDRESS 1 7 a ✓ tb.10Mc s _ INDIVIDUAL LOCAL-AGENCY �J STATE-AGENCY <br /> \ -O IIID J 6 ORPORATION PARTNERSNP COUNTY-AGENCY C FEDERAL-AGENCY <br /> CITY NAME <br /> STATELo ZIP COCE PHONE s WITH AREA CODE <br /> Go�02- 3� _I la�U-S�lo� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 , <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I SELF-INSURED - <br /> ✓ COI b WK�I� 2 GUARANTEE L__�] ] INSURANCE 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 tc 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 77 II. 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 NAM (PRW TED 6 SIGNATURE) \ ! APPLICANTS TITLE DATE NTW YN <br /> AEAR <br /> � % . Z �� \ `� ENv, (a Vnc� ( rn)ti. �'12►��G�I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY Is \ JU ISDICTION x FACILITY x <br /> LOCATION CODE OPTIONAL CENSUS TRACT s •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B. UALE`bS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> CORM A(591) TOR0033A.5 <br /> �'�;•. S4N �;v�C�v,.,1 C� . �kvv . \lea\�� �,d. BoX 34$ <br />