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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4 N0 <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT [E!fS CHANGE OF INFORMATION O 7 PERMANENTLY CLO TE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORFACJ TY NAME ��P)t��N MEOFOPERATOR <br /> MegiFr`5QB6 Ir <br /> ADDRESS NEAREST CROSSgREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP C;E,,,/ SITE PHONE#WITH AREA CODE <br /> t. CA <br /> I/ BOX <br /> TO INDICATE 71 CORPORATION F7 INDIVIDUAL = PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION Q 2 DISTRIBUTOR = ✓/ IF INDIAN 1#OF P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH ARA ODE PAYS: <br /> NAME(LAST.FIRST) <br /> S. <br /> NIGHTS: NAME(LAS I FIRST) PHONE#WITH AREA CODE LNIGHT NAME(LAST,FIRST) PHONE I WITH ABEA <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME 3AIJ" CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS box to Indicate QINDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME _iTATE ZIP CODE PHO E <br /> 7TH AREA CODE <br /> Ill. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME OF!M14 of N <br /> I LZM CARE OF ADDRESS INFORMATI N <br /> "C <br /> NITI, 0 K <br /> MAILING OR STREET ADDRESS ✓ box Vindicate Q INDIVIDUAL L2 LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP =COUNTY-AGENCY Q FEDERAL-AGENCY <br /> ITH <br /> CITY NAME STATE ZIP CODE PHONE NP <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4_T4_] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 1D indicate iQI SELF-INSURED 2 GUARANTEE = 3 WIANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION E:R4 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 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 /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY <br /> W OU 4TY# JURISDICTION# FACILITY# <br /> -�XeAiIO FT17 <br /> LOCATI? <br /> E -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> t d <br /> THIS FORM MUST BE ACCOMPANIED BY 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 /> AML <br />