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02/15/1994 17:52 <br />209339921 • <br />ED BROCKMAN <br />0 9 <br />STATE OF CAUFOWGA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />MARK ONLY 1 NEW PERMIT RENEWAL PERMIT _ S CNANOE OF INFORMATION ` J 7 <br />ONE ITEM Z INTERIM PERMIT AMENDED PERMIT � S TEMPORARY SITE CLOSURE <br />I FACII rrY15ITE INFORMATION A ADDRESS • (MUST BE COMPLETED) <br />PAGE 01 <br />OBA OR FACILITY NAME I NAME OF OPERATOR <br />' <br />ADDRESS <br />NEARESTCROSS STREET i PIIrtCEl F IpPIIONAU <br />r <br />MAILING OR STREET ADDRESS <br />CITY NAMESTATE <br />DP CODE SITE PHONE • wlTu AREA CODE <br />'r <br />CA i 9s 3 <br />wx <br />ToiNP TE CORP(MTON INOMIDUAL PARTNERSAP _ LOCA 40EKY - COUNTY44IENCY STATE-AMCY - "WERAL.AGIENCY <br />DISTMC1S <br />TYPE OF BUSINESS a 1 C,^S STATION T Di$TRIGUTOR <br />• OF TANKS AT SITE <br />E. P. A. t D • (aPnoniq <br />Q 3 FARM C'1 A PROCESSOR Nall's OTMER <br />�J RESERYA0IN7N <br />OR TRUST LANDS <br />f <br />(Q13 J EMERGENCY CONTACT PERSON (PRIMARY) <br />DAYS: NAME (LAST, FIRST) PHONE 9 WITH ARE; <br />q- 23k3k <br />NIGHTS' NAME (LAST, FIRST) 1 / PHONE s WITH ARE; <br />nvul tce ttdcnDUATinN . IRAItCT RF ('_nkmol FYRnl <br />EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />E (LAST, FIRST) ze9-4 y1t7s <br />5►G^ 071/ <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />wx Ib IRD vvj t `,� LOCAVA"Kv �STATE•AGENCY <br />C C00I1110ATION PARTNERSiWP COUNTYAGENCY ` FEDERAL AGENCY <br />CITY NAME <br />STATE j ZIP CODE PHONE s WITH AREA CODE <br />I <br />111. TANK OWNER INFORMATION - (Mti T tit <br />AME OF OWNER <br />CARE <br />MAILING OR STREET ADDRESS <br />✓ box b WcN• _-INOP14Xm LOCAL•AGENCY _ STATE.AGANV <br />�iL� <br />10 Z Sw Q� lft $+W&d-�' aapRATiON PARTIS RSHIP ^ CCUN►Y AGENcr _FEDERAL At:Exc, <br />CITY NAME 1N 1. K•r' ! STATE jIP CODE I PWONE *WITH Ar7EA CODE <br />E 70 _ JO 3 <br />IV. BOARD OF EOUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Cail (916) 323-9555 if questions arise. <br />TY (TK) HO =41 4!• <br />I..�_ <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ �, b, _ I SELF-INSURED _ 2 GU+%.ANTEE --- 3 iNS>JRANCE .... 3 SURETY GOND <br />S LETTERDF CREDIT 6 EXEuPTION N OTHER <br />111 VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 Or tl k chocked. <br />f C-ECK ONE 3OX MDiCATING WHICH ABOVE ADORESS SHOULD BE USED FOR LEGAL NOTIFiCA-ONS AND 51LL'NG: I <br />f THIS FORM HAS $EEN COMPIXTED UIVOFR PENALTY OF PERJURY AND TO THE BEST OF MY KNOWLEDGE is TRUE AND CORRECT <br />A.'P_G S%AME.PRIF,TEDASiGNATUREI <br />APP;XAN-S TITLE <br />DATE MCN --CAV v_AA <br />��-T • M� R <br />y <br />`!r <br />LOCAL AGENCY USE ONLY <br />COUNTY • JURISDICTION P FACILITY s <br />_MATICIY CODE 00GIDN4L CENSUS TRACT■ - biTN7NAl S,:PVjSCq - D:S7gICT CODE - OPT/ONAC <br />THIS F 7RM MUST RF AIX:OMPANIFO BY AT I EAST III OR MORE PERMIT APPLICATION -FORM B. UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />^C ,a A ,'2 9•I FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />CrA 7Q:iJ =c <br />Cod <br />