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y0"" C <br /> a <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 ., <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> • C�(IFOA N' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY <br /> It�' <br /> ONE ITEM 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT E 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> v�JoL_.sL- ,-;,-s . 6 1) 0:7ple4 -- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> '12--l'01 W, ivick -4-" -r_ 1:51 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> C)C-k_4-,_ ,rte CA Gi E6 2X>-7 (-ZCA) i -)3 <br /> ✓ BOX <br /> TO INDICATE CORPORATION J�INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS } 1 GAS STATION = 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> /� RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAYE(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Ms s �r-a ('II 4) G-12--'Iibz5$ PHONE 9 WITH AREA rOr)F <br /> NIGHTS: NAME(LAST,FIRS11 PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODEII. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> Vr,k&'� Ck EJrr til <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY <br /> � �STATE-AGENCY <br /> Wj 2—Cl ;�S CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMES f STATE� ZIP CODE �g PHO <br /> NE#WITHH ARREEA CODE <br /> .�k <br /> I3I,-� C—A Z LD — 1)'1 r.J l 2" —ILP G f- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 1Uni nr, ©;I C o' <br /> MAILING OR STREET ADDRESS 15v ✓box to Indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1afz-.3� C,.A q 2.m 2-) l I")512- 1 15'? <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ4 4 - 4 4 00 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED [:j 2 GUARANTEE E::] 3 INSURANCE 4 SURETY BOND <br /> =5 LETTER OF CREDIT =6 EXEMPTION 0 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.[—] 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 NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> Leo," L.Q,' 14 Qi <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> G3 /o is SSS <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 />