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STATEOFCAUFORMA W+ <br /> • - STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> :o vI d <br /> yJ . <br /> MPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIL TY NAME NAME OF OP TOR <br /> It <br /> 0 • M10 <br /> ADDRESS NEAREST C SS STREET PARCEL/OWIONAL) <br /> tat W <br /> CITY NAME STATE ZIP CODE SITE PHONE•W AREA CODE <br /> S c FVr� CA Syo 5 Q�/ <br /> TOINDox f�CORPORATION IVIDUAL =PARTNERSHIP f�LOCAL-AGENCY E]COUNTY-AGENCY (] STATE-AGENCY 0 FIEDERALAGENCY <br /> ��^^�. DISTRICTS <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR I� RESERVATION 1 IF INDIAN A OF TANKS AT SITE E.P.A. I.D.x(optiana) <br /> 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) E N WITH ARE CODE DAYS: NAM (LAST,FIRST( n 4�g v� �J�/� <br /> M I+A66N MA Mut au4 9 '�l_ 3i ( 00 0 7 <br /> NIGHTS: NAME(LAST,FIRS NE•WITH AREA CODE NIGHTS: NAME(LAST.-FIRST) O3 ^! <br /> .54) a-99 Se5u' j <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMCARED ADDRESS INFORMATION <br /> �}L�LL o L L C.0 <br /> MAILING O STREnETADDRESS ✓ MmuldnA = INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> V\� O a CORPORATION Q PARTNERSHIP COUNTY AGENCY M FEDERAL-AGENCY <br /> CITY NAME TEZIP CCSCA PHO�L WITH�� DE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF,GwN R / /� CARE OF ADD SS INFORMATION <br /> MAILING <br /> ✓✓O\OR REET DRESS ✓ boab 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> U OZ CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITU NAME /j � SATE ZIP CODE �Z7 isPH E:a`WITH�ES CODE <br /> IV. BOARD OOrFNEQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY <br /> ��0 66 <br /> TY(TK) HQ F4-[4—]- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa NUAkare SELF-INSURED M 2 GUARANTEE E-1 S INSURANCE (]4 SURETY BOND <br /> 5 LETTEROFCREDIT =6 EXEMPTION 0 W 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.tjj� III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICAN ME(PRWTE &LZ SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY# <br /> L TION CODE -OPTIONAL CE;U'Tr1AfTR-OPTIONAL SUPVIS -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 /> FORMA(691) FOII A3 <br />