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0 <br /> e.OUR e <br /> STATE OF CALIFORNIA AeP - <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F-] 1 NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION 0 7 PERMANENTLY C <br /> ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> O C 1 # 3 Co%_ s \T N <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 202 W. Pwmeg LANE KELLY <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> GToC_KT0N CA 95205 209- 951- 290® <br /> I/ BOX <br /> TO INDICTE 52 CORPORATION INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY (] STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS m 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESE RVAT ION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS I 3 CAL 000 0'39 LOo <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) GI I(p-4031- 6915 <br /> SMITH COL.L-eIM 209-95-1-2900 Lou <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) 9CO-2.79-B5-7L <br /> SMSI VA Q>L6_eE:_N209 - 4(,2-322(0 241.18 EMER e sic PHONE#WITH AREA OQr <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> LAW� DGv�co PM�NT INC <br /> MAILING OR STREET ADDRESS ✓ box bIndicate INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> 8101 Ke-L-LY OF, Sm- CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SToGK o IA C 9520` - <br /> K OWNER INFORMATION-(MUST BE COMPLETED) <br /> WNER CARE OF ADDRESS INFORMATION <br /> P 01 L Co Lou PAtZ1s1 <br /> ING OR STREET ADDRESS ✓box lo indicate 0 INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> 28(0 PRoSPEc.T PARK DR # 3460 5Z/CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> RAP 0 QK�OVA CA 95r070 91(v-0031- 915 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(IM HQ4 4 - 0 2 -71-7 0 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box toindicate 1 SELF-INSURED Q 2 GUARANTEE [073 INSURANCE (]4 SURETY BOND <br /> O 5 LETTEROFCREDIT 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 check <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. <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 8 SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> C rt= br_- N& ARo t WtA. a 0- 2.5.95 <br /> LOCAL AGENCY USE ONLY tv <br /> COUNTY <br /> ,I.rJ--A�# �� � JURISDICTION# FACILITY# <br /> 2- <br /> LOCATION QQQE -OPTIONAL CENSUS TRAC`#OPTIONAL SUPVISOR-DIST ICT CODE -OPTIONAL <br /> 01 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OFOR TION ONLY. <br /> FORM A(5-91) �� FOR0033A-5 <br />