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STATE OF CALIFORNIA ..... <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH WILITY/SITE <br /> C <br /> MARK ONLY I NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANEN CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME -a NAME OF OPERATOR <br /> 15"ecle C c-Ic fold <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> $11v e_-k k CA 5—01_0_9� <br /> v Box <br /> TO INDICATE 71 CORPORATION 71 INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY F7 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION = 2 DISTRIBUTOR = / IF INDIAN 7A71.D.#(optimal) <br /> RESERVATION <br /> 3 FARM 6 OTHER OR TRUST IANOS <br /> ER RY'C6k1_)=,PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional' <br /> DAY"AME(LAST FIRST) PHONE#WITH AREA CO DAYS: NAME(LAST,FIRST) <br /> Zd4e 0: on ?-67 2 - - C--,$�;p PwnKir A <br /> NIGHTS: NAWE(LAST,PIRST) PHONE 9 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> E VA,'a'W' S S'4 PHQbIE#WITH ABEA 9912E <br /> ii. OPE Y- ER INF6 •(MUST ED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Z k14 <br /> /WAILING OR STREET ADDRESS box b IrWicals = INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> &x 54,- CORPORATION = PARTNERSHIP F7 COUNTY-AGENCY F-1 FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#NTH AREA CODE <br /> 11 k7 e4 1 7 <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box bindica M INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION = PARTNERSHIP Q couNry-AGENCY Q FEDERAL-AGENCY <br /> 'qTY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.80 D' N UST STORAGE:FEECOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(T F4 4 <br /> HO _Tdo I o 3 -Fol <br /> 1 1 _pT-3 <br /> (M' <br /> V. PETR UM UST FINANCIAL RESPONSI •(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> =2 GUARANTEE = 3 INSURANCE'_� 4 SU BOND <br /> 5 LETTEROFCRED[T =6 EXEMPTION r7 99 OTwr� 7 1 <br /> Vt. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the I owner unless box I or 11 is coe/ded. <br /> =4 UR <br /> SL BOND <br /> box I or 11 is C d. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWL�E,IS TRUE AND?COR CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS <br /> wTITLE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> am F71717 1. 1/ 13 F)4e 0 3-3 <br /> LOCATION CODE -OPTOM4L CENSUS TRACT# -OPnONAL _7TUP_vIS0R-DISTRICT CODE -OPTIONAL <br /> 0/ 11 ) 3 oOD I 31_rll 3 <br /> THIS FORM MUST BE ACCOMPANIED BY-AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOROMM-5 <br />