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17W A= <br />r . _.. <br />STATE OF CALIFORNIAw' M1P <br />STATE WATER RESOURCES CONTROL BOARD 3` , <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />Im <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ='J� 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOS <br />ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE gl <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OFOPERATOR <br />KIETH 66 15'r' Gf-I VfZc)P <br />t ►i:rH RIAKIOA o7c. <br />ADDRESS <br />)65o H(EHU),AYC(cf 00>_T)'1a►�(,slI <br />NEAREST CROSS STREET <br />PARCEL#( IONAL) <br />(� CORPORATION (] PARTNERSHIP <br />COUNTY -AGENCY 0 FEDERAL -AGENCY <br />005 i� I ria <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />✓ BOX <br />TO INDICATE FV_M CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR/ <br />IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />RESERVATION <br />3 FARM 0 4 PROCESSOR = 5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE` <br />�)5T K)ET, H (%Q13-33 ,-!f'a; <br />DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME (EMT, FIRST) ONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />6H C*{'.g1.,1 2- HR 5, 95 C> e',4 �, — & . <br />'. I PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />&f41& c K,i�t�vC�UGTS C <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />MAILING OR STREET ADDRESS�✓ <br />bindicate INDIVIDUAL <br />,CORPORATION <br />LOCAL -AGENCY STATE -AGENCY <br />CITY NAME <br />(� CORPORATION (] PARTNERSHIP <br />COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />111 <br />M© <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />© -9 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNERCARE <br />qHEF AA <br />OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL LOCAL -AGENCY Q STATE -AGENCY <br />CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # 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 - <br />V. ;PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />box to indicate 1 SELF-INSURED 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br />D 5 LETTER OF CREDIT 6 EXEMPTION 99 OTHER <br />VI. LEGAL NOTIFICATION AA B1 61�1Ex`i�b{3t 5' ° 1_e�al notification and billing will be sent to the tank owner unless box I or II is checked. <br />CHECK ONE BOX INDICATING ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. � II. � III. <br />-1 OW- - <br />S <br />THIS FOA IBEEN L ER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S NAME (PRINTED & SIGNATURE)PPLICANTS TITLE DATE MONTHIDAYNEfAR <br />LOCAL � WE ONLY'// .; <br />COUNTY # JURISDICTION # FACILITY # <br />M 1 1 1 51 <br />LOCATION CODE -OPTIONAL ICENSU$,TRACI # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONALS T �ifc-j /177 <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 />