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i <br /> STATE OF CALIFORNIA � <br /> STATE WATER RESOURCES CONTROL BOARD a g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ;mom ss; <br /> ��-- COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY LJ 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F72 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME I NAME OF OPERATOR <br /> O' ..I-r.'c. <br /> ADDRESS NEAREST CROStATREET PARCEL 0(OPTIONAL) <br /> CITY NAME STATE ZIP CODE S PHONE I WITH AREA CODE <br /> ca 9s-� �� <br /> I/ Box <br /> TOINDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Q 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN I OF TANKS AT SITE E.P.A. I.D.I(optional) <br /> RESERVATION <br /> 0 3 FARM n 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS: NAME(LAST,FIRST) �1) g Yg_q l� <br /> --^�wrict S'- YR. El��.s•►� wt;lac i <br /> NIGHTS: NAME(LAST,FI ST) P ONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) (ZG*) V -PHONE;#WITH REA CODE- <br /> (4 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE <br /> c.* Grp grzo� (io1 9y - <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME,OF OWMER CARE OF ADDRESS INFORMATION <br /> W��'/W' T —7—oc- <br /> MAILING OR STRE T A �ORESS ✓ box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION = PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE PHONE I WITH AREA CODE <br /> r C44 5­70 f z,05) <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 /> ✓ <br /> box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE <br /> Q J INSURANCE Q 1 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br /> Vi. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.1:1 it.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT r�Y <br /> APPLICANT'S NAME RINTED&SIGNATURE) APPLICANTS TITLE DATE /M(OlNT/WDAYNEAR <br /> �_Xly /e' k(- 0til o>~ 1�is -7 �T 1 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# b03q 1(a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT I -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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) <br /> FOR003JA-5 <br />