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• . tsoUR e. <br /> STATE OF CALIFORNIA hr P o0 <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <��� y: <br /> •C�llf o�Nf <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY L] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT L_� 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ? I <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPE TO <br /> i <br /> VRO� -- --- ------ - E' ' ' <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 07-3(,7 AI _ <br /> CISME STATE ZIP CO W <br /> TE PH NE# ITH REA CODE <br /> _�ol�.t CA I C=/- <br /> I/ <br /> TO DICATE CORPORATION [INDIVIDUAL [_] PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY E:1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR / IF INDIAN I#OF TA S AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR = 5 OTHER ORRTRUST LANDS ESERVATION !' L <br /> /� ZGib7cj <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LASY FIRST) 77Z— 7 !'( <br /> NIGHTS: AME(LAST FIRST) PHONE#WITH AREA CO� NIGHTS: NAME(LAST,FIRST) <br /> G/ EI/,�o c� i - <br /> 77Z-- 93o I __1E#WITHAREACODr <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY <br /> STATE-AGENCY <br /> O_ CORPORATION (] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 0 ZIPf PHONE�D WITH AFI A CODE <br /> � S _ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) N 8 Z `-/7 <br /> NAME CIF OWNER CARE OF ADDRESS INFORMATION <br /> M G OR STREET ADDRESS ✓ box In indicate L=1 INDIVIDUAL LOCAL-AGENCY [7] STATE-AGENCY <br /> D+ x 5�'v CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY � FEDERAL-AGENCY <br /> CITY�N�AME ST ZIP <br /> F � /o)g H,ZEA C E <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)`33223-9555 if questions arise. `7J <br /> TY(TK) HQ _�-IO 131111111,5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate ! 1 SELF-INSURED [�_) 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT E-1 6 EXEMPTION CJ 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- it.❑ 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) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY 111, <br /> COUNTY# JURISDICTION# _ `\ fA6tL-FF'fik- <br /> --------- --- <br /> LOCATION CODE OPTIONAL CENS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> © f1� <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(1z-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS C <br /> 1i)h0033A-R6 <br />