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• • � � SOUR P <br /> PC . CO <br /> STATE OF CALIFORNIA �? <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD W , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a a 0 <br /> COMPLETE THIS FORM FOR EAC ,.ACILITY/SITE <br /> MARK ONLY ❑ i NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C ED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ® 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME t NAME OF OPERATOR <br /> xv' o •a�c.��� 2.�'s3 ?et' SAcou�a <br /> ADDRESS NEAREST_QROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE tZIP CODE SITE PHOI#WITH AREA CODE <br /> z1b tzo CA QS".o1 -1'x-5 SL <br /> ✓ Box <br /> TO INDICATE CORPORATION INDIVIDUAL I=PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORRESE F INDIA <br /> N #OF KS AT SITE „ E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENC RSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PL40NE# ITH AREA CODE DAYS: NAME(LAST,FIR T) ?_-m-b <br /> zm Nvvr c� l �'18-SS SIL co i ��rt'CeNAn+Ce �'0 3y9 <br /> NIGHTS: NAME(LAST.FIR T) INE# IITH AREA CODE NIGHTS: NgME(LAST,FIRST) �� 2'I2rb3t1� <br /> Mfmh fce� og ��t 20°11 a1"'1�-SSSS I�2Cb A� �rt �1 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> A91co � cw-s S <br /> MAILING OR STREET ADDRE S ✓box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> O �03� CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE#WITH AREA CODE <br /> Rta-yes qb,)02- 1003 c,�y bio-S�o� <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWN CARE OF ADDRESS INFORMATION <br /> ,acA Qsr wc, Co . swaS <br /> MAILING OR STREET ADDRES ✓ box to indicate = INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> R 4 �o3'Q CORPORATION = PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE# TH AREA CODE <br /> Q �0. Co, � 14-)02._taom cn ok fid- K40 q <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 F4 - Q 1 6C) I S Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> Fi 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.❑ II.❑ 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICA NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE AA 11 DATE MO TW YNEAR <br /> �20�9�o <br /> LOCAL AGENCY USE ONLY L _ /7 <br /> COUNTY# JU TION# FACILITY# 6K <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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(5-91) FOR0033A-5 <br />