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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Z <br /> A <br /> COMPLETE THIS FORM FOR EAC/ACILITY/SITE <br /> MARK ONLY 0 I NEW PERMIT a 3 RENEWAL PERMIT Evs CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE C/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORFACILITY NAME NAME OF OPERATOR <br /> ar <br /> V <br /> WM:56 <br /> ADDRESS NEA CROSS STj4EFT PARCEL N(OPTIONAL) <br /> I I <br /> zP0,51 par_,fi it " I <br /> _Coi " "I <br /> CITY NAME STATE Z11F PHO #q WITH AREA CODE <br /> 5hn'&v,z � (zo�_l Ig-s5o q <br /> ./ BOX 0 PORATION INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TOINDICATE DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR TANKS ATSITE E.P.A. I.D.#(qptional) <br /> Q 3 FARM RESERVATION <br /> = 50TH=ER 3 1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS-,NAME(LAST, RST) PHONE#WITH AREA CODE DAYS:MST gFI,ST) <br /> L <br /> OZ13-4 <br /> K q4 4 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PLIQNE g WITH REA COQE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME V <br /> CARE(AADO RESS INFORMATION <br /> MAILING OR STREE11FADDRESSINDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> A t541t3f. ✓box to indicate <br /> CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY <br /> �+71P CODE ONE#WITH AREA CODE <br /> 61/00 <br /> 111. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S�� gio <br /> MAILING OR STREET ADDRESS ✓ box to 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#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO _F_1_j ()j ?_jqj!5jMy <br /> F4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> V box to indicate Q I SELF-INSURED = GUARANTEE 31NSURANCE 4 SURETY BOND <br /> s LETTER OFCREDIT V6 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 11 v hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= It.FYI, Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONT1,1OAYNE= <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 37 FT-7 IIIZ11167T <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 01 1 -23. 60 1 3�j <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) FOROM3A-6 <br /> K) <br /> _00 <br />