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•e•u�w e <br /> STATE OF CALIFORWA <br /> STATE WATER RESOURCES CONTROL BOARD - *� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> DD n. . <br /> c•t•own- <br /> • COMPLETE THIS FORM FOR EACH FACIL ITE <br /> MARK ONLY ❑ 1 NEW PERMIT 7 RENEWAL PERMIT ❑ S CHANGE FO 7 MANEN Y CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT 9 TEMPORARY SITE CLOSURE I D <br /> 1• FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME � � � j NAME OF OPERATOR <br /> yyJMy6 <br /> ADDRESS I NEAREST CROSS STREET I PARCEL 0(OPTIONAL) <br /> CITY NAME I STACA ZIP CODE SITE PHONE;WITH IJ O,2�6 O <br /> ✓ Boxb/► <br /> TO INDICATE ORPORATION Q INDIVIDUAL Q PARTNERSHIP p LOcAL•AGENCY Q COuNTY•AGENCY Q STATE•AGENCY I] FmERAL-AGENCY <br /> 06TRICTS <br /> TYPE OF BUSINESS a 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE I E.P.A. L 0.s(Con") <br /> RESERVATION <br /> 1 FARM a PROCESSOR 0 S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE g p DAYS:•NAME(LAST,FIRST) <br /> v�J�/7L GO <br /> NIGHTS: NAME ft.AST.FIRST) PHONE s WITH AREA CODE NIGHTS:NAME(LAST, A <br /> a � c <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> &14 <br /> MAILING OR ST E CRESS ✓ box 0A0ieaa p INONDUAI J LOCAL-AGE14CY Q STATE-AGENCY <br /> 1 Q S I []CORPORATION C1 PARTNERSHP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME �--. - A D STATE _ I ZIP COOE�� [( i PHONE G �TH _& <br /> III. TANK OWNER INFORMATION-/(MUST BE COMPLETED) /t�'/1�L__ <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓WX bsftm p INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHP p COUNTY.AGENCY Q FEDERAL-AGENCY <br /> CITY NAME I STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TIC) HQ4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> L <br /> box b idem Q I SELFdNSUREO p 2 GUARANTEE m <br /> p S LETTER OF CREDIT p 6 omwUl- OTHER p SURETY 80N0 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ IL❑ IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERIURY,AND TO THE 8EST OF MY KNOWLEDGE,JS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE GATE MONTK 3AYNEAR <br /> LOCAL AGENCY USE ONLY w vQ <br /> COUNITY s JURISDICTION s FACILITY <br /> LOCATION CODE -OPT70NAL (CENSUS TRACT s•QP770NAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> ?-3 &0 <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 /> FOAM A(5-91) <br /> FCAORl3A-S <br />