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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> s�em• , R <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ; t �1a <br /> 1 <br /> CO LETE THIS FORM FOR EAC ,LrrytsrrE <br /> MARK ONLY n I NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PER ENTLY TIE <br /> ONE ITEM2 LNTERIM PERMIT a AMENDED PERMIT 6 ,'cMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> EBRD `LITYNAME _ � i NAW OF OPERATOR <br /> AC RES i NEARE-- ROSS STRJEET PARCEL*(OPTIONAU <br /> C'Y NAME STATESITE: � i SITE PHONE s WITH AREA CODE <br /> ✓ <br /> G't ca q <br /> 30X 7. <br /> TOINDIC1 COR RATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 1 COUNTYAGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION j 2 'DISTRIBUTOR ✓ +F INDIAN s OF 7ANKSAT SITE E.P.A. I.O.a(OPnonal) <br /> ESERVATION <br /> z FARM Ci a PROCESSOR n 5 OTHER `}ORaRUSTLANDS JC <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS. NAME(LAST.FIRST) PHONE a<WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME,1L ST.FIRST) <br /> OL40NE:WITH F C--C;: <br /> IL PROPERTY OWNER INFORMATION• MU BE COMPLETED <br /> NAME i CARE OF ADDRESS INFORMATION <br /> Ma1LIN R STREET AC ESS ✓ 7=a WNW= 7-7INDIVIDUAL �LOCAL-AGENCY � STATE-AGENCY <br /> b2Z <br /> _ �tv.�1Y.Y� = OO <br /> C�RRRPORATIONNi� � PARTNERS/HIP��.-{? COUNTY-AGEENCCYY � FEDERAL-AGENCY <br /> C;TY/—/ i S�� ! '/� E L i PHONE (I AREA COCe �� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> DAME W R CARE OF ADDRESS INFORMATION <br /> I <br /> MAILIN R STREET ApqRESS• ✓ got oCau --, - <br /> �] '7INOIVWUAL LOCAL-AGENCYSTArE•AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY J FEDERAL-AGENCY <br /> CITY NAM STA IIP CE H s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4!- G7+ O 151,0i <br /> V. PETROLEUM UST FINANCI ONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> on lomaicate I SELF-INSURED 2 GUARANTEE 1 INSURANCE 1 SURETY SONO <br /> 5 LE7FROFCREDIT 5 EXEMPTION 49 OTNEA <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II' ked. <br /> C:-iECK CNE BOX INCICATING WHICH ABOVE ADDRESS SHCULD BE USED FOR LEGAL NOT1FiCATIONS AND BILLING: 1.f 11.! IIL <br /> THIS FOAM NAS BEEN COMPLETED UNDER PENAL TY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE.;S TRUE AND CORRECT <br /> AROI_:CANPS NAME,?:NTED&SIG,NATUREI APPLICANTS Tir,-F- CATE MCNT60AYtYEAR <br /> LOCAL AGENCY USE ONLY <br /> t <br /> COUNTY:t v y' JURISOICTION.x FACILITY <br /> CAT Cv rE ?';CNat C�ESUS'RACT a -OPTS $ Pv:SC. ::S'AIC' ,DE -CPTCNAC <br /> T HIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE!NFORMATICN ONLY. <br /> FILE THIS FORM WITH THE LOCAL AGENCY MIPLEMENTING THE UNCERGRCUNO STORAGE TANK REGULATIONS <br /> n"Gi3A-^e <br />