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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A •.`�" •, <br /> Y� O <br /> ORM FORE <br /> MARK ONLY NEW PERMIT 7 RENEt"I4: ?EalAtL 5 CHANGE OF ;NFORMATION f- 7 PERM SITEONE ITEM a' s AMENDED PERMIT. 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&AD S-(MUST LET ED) <br /> R FACR-I AME J NAM E TOR A / /i <br /> A E (�1_ NE 'T ROSSSTREES- PMCEL9(oPfplWy <br /> CITY N �� � I <br /> STATE I 2(p � ` SITE. s <br /> CA : l <br /> ✓ Box <br /> TO INDICATE CORPORATION lNplYltxJAL =PARTNERS-D LOCAL•AGc'MCY f--7 CoiNP/-AGENCY {-STATE-AGENCY FEpMX,%MNCq <br /> ,^,SIRICTS <br /> TYPE OF BUSINESS r__i I GAS STATION 2 DISTRIBUTOR — '— ✓ IF INDIAN s OF AT SITE E-P,A. L 0.s ftemmg <br /> RESE <br /> !� A FARM `- t PROCESSOR — 5 OTHER �OR TRUSTVATION LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> �► (LAST,F ST) E s WITHi ARE.Za3E DAYS: NAME(LAST.FIRST) <br /> NIGHTS- NAME(LAST, ST) s WITH AREA CO^.E NIGHTS: NAME(LAST.FIRST) <br /> s WITH AMA CQQE_ <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED! <br /> E CARE OF ADDRESS INFORMATION <br /> i <br /> M (i R STREET ESS / ✓ tieso _ MOIVIOUAL =1 LOCALAGE CY Q S ATE4aR CY <br /> �- _CWOMTION _ PARTNERSi#P f�"1 OOt1NryAGENCY ML <br /> F AGENCY <br /> CITY ST TE ; CODE i PHONE s WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N ca CARE LF ADDRESS INFORMATION <br /> MAIL:' T 'T DRESS x.bulataa _u101V10t1A1 _LACA44,GENCY l=STATE•AGEICY <br /> _:ZRPORATIM _ sARTNERW ` COUNTY•AGENCY 0 FEDEW AGENCY <br /> C TY STATE i ZIP=E PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> TY(TK) HO 74Z,- <br /> �� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ow q masa - I SELFIN!WW ARANTEfi Q♦SURETY am <br /> _ S LETTEROFCRE-OT cr E!APTiCN ga OTWA <br /> VL LEGAL NOTIFICATION AND BILLING ADDRESS i aaa!notification and billing will be Sent to the lank owner unless box I or 11'dwcked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED.=OR LEGAL NOTIFICATIONS AND BILLING: I.= IL V <br /> UI. <br /> THIS FORM HAS BEEN COMPLETED LAWER PE,VALTY,^,F.zE-LURY,AND TO TriE BEST OF MY;0VOWLEDGE,IS TRUE ANO CORRECT <br /> APPL'CAVT'S NA'.:E;PRoVTED&SIGNATURE: APPL,CANTS T:%5 - DATE MONTWDAYnEAR <br /> LOCAL AGENCY USE ONLY <br /> CCUNrYx _n'ij�ICTIOMz FACILtTYa <br /> Oc;A T'^.� C^x^= :P'MNAL c`a: '�4s - ':Y»: ��':SOA• IS_n' C.:DE -OP770NAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST;T;OR MORE P R41IT APPLICATION- FORM B, NLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> A,1.1 3. FILE THIS FORM WITH THF I-ICAL THE UNDERGROUND STORACF TANK REGULATIONS N <br /> � �/ FOM33A•R6 <br />