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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD $ - <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH F ILRYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE w-- <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAMETT NAMEOFOPERATOR <br /> S V <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPfgNAu <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> c- ¢S 'n �a �9Y67dY <br /> TOI/ BOX INDCCATE CORPORATION ( 1 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL AGENCY D COUNTY-AGENCY Cl STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.*(apt ai) <br /> RESERVATION <br /> ❑ 3 FAR _ ESSOR ❑ 5 OTHER OR TRUST LANDS <br /> GENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA E(LAST,FIRST) PHONE X WITH AREA COVE DAYS: NAME(LAST.FIRST) <br /> ao -99 0v <br /> MHTS: <br /> NAME(LAST.FIRST) PHONE#WITH AR ODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box IDINkaM INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEC PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓box 0inEk:Me Q INDIVIDUAL O LOCAL-AGENCY (]STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP (]COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME- STATE ZIP CODE PHONE#NTH AREA CODE <br /> IV. BOARD 0 ATION UST STORAGE FEE COUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) 4 4 -� <br /> V. PETROLE SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0 micals O I SELF-INSURED 2 GUARANTEE 3 INSURANCE d SURETY BOND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION 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 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ II.❑ III.❑ <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 S SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> __ <br /> LOCATION CODE OPTIONAL (CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a 3 A'D 3d 3 00 ? y <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(12.91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ` ' FOR0033A P6 <br /> �/ 1- <br />