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- ' QJ •4sp I, t <br /> STATE OFCALIFORNIA •� �'* <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A r. <br /> COMPLETETHIS FORM FOR EACH F Y/SITE _l <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT 21's-CHANGE OF INFORMATION [] T PERMANENTJ�YOCO.. <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE r <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMNAMENAME OF OPERATOR f I <br /> LGn LO/ c 1 GMfS l wn S� cD� 1 <br /> 14 <br /> ADDRESS ^ NEAREST CROSS STREET PARCEL#(OPTQNAL) _ <br /> CITY NAME <br /> `J STATE ZIP CODEf 0 SITE PHONE#WITH AREA CODE <br /> CA 5 3 3 Q <br /> Box CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY COUNtY-AGENY Q STATEAGENCY FEDERAL,GENCY <br /> TOIN DISTRICTS - <br /> TYPE OF BUSINESS Q 1 GAS STATION 0 2 DISTRIBUTORQ q-/ IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. L D.#(OPUG ap <br /> 0 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) \ PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Lan <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) WITH AREA Coop <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME La11S'h'\\ ,( CARE OF ADDRESS INFORMATION <br /> O+� J'}�fC v <br /> MAILIN2OR rT ORESS ✓W#blmb Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> O Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL+LGENCY <br /> CITY NAME STAei ZIP D � .l PHONE#WITH AREA CODE <br /> LC�c-�n Y-O �. V <br /> I <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ ba bubk0# Q INDIVIDUAL Q LOCAL-AGENCY Q STATSAGENCY I <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <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 MIFTHOD(S) USED <br /> ✓Em binEkaM Q 1 SELF-INSURED Q 2 GUARANTEE Q 5 INSURANCE Q A SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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 Ch ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O IL' III.a �' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY C <br /> COUmNTY# JURISDICTION# FACILITY# <br /> FFEI v 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONNLLY.1A}}} <br /> FORMA(5-91) / <br />