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STATE OF CALIFORNIA <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A D <br /> • Cit IFUR N.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> mom— <br /> MARK ONLY F_� 1 NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLYSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT F-14 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE t 4:::!> <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 1 NAME OF OP RATOR �r <br /> ��✓t � S <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> s CA 5 <br /> ✓ BOX <br /> TO INDICATE RATION 0 INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY [] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS1 GAS STATION [::] 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FI ST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> �h �J, izS-zYy /' PHONE*WITH AREA(QDF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME p ® Q CARE OF ADDRESS INFORMATION <br /> MAILINGr STREET A DRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> O O t OZZ CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE#WITH AREA CODE <br /> yk G 9 34 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �C'►x t� G�,LAk-5 <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 'G CJ 7 Z p terry t �-� (�CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> W\.C. V-.e—c 64 l 53�L Zoci 23.5_ 7S <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -I ©I-L 1 1619111 <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 4 SURETY BOND <br /> D 5 LETTEROFCREDIT O 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.D 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 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Fe AN K 'Zr <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 />