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A6 . <br /> STATE OF CALIFORNIA - `s <br /> STATE WATER RESOURCES CONTROL BOARD _. <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� v <br /> `�xI�OPYP <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT [-] 5 CHANGE OF INFORMATION L] T PERMANENTLY CLOSED S <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) ? <br /> QK.(xOR�FACI�LITV fIAME NAME OF OPERATOR <br /> AlI11DiiD�LRE55 N PES CROSS EJ1T K``\`/1vTlVP`ARCEL#(OPrIONAU <br /> V AN e, <br /> CITY NAME 0` STATECA Zt0. % A^ PHO E ITH�AREAOC�X <br /> ✓ BOX ''yy�� UUII U1 AI f_l\ 8 <br /> TOINDICATE D CORPORATION O INDIVIDUAL L]Q PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY � FEDERAL-AGENCY <br /> /_ DISTRICTS <br /> TYPE OF BUSINESS N1 GAS STATION a 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(oplianap <br /> 3 FARM E=] RESERVATION <br /> 0 4 PROCESSOR5 OTHER OR TRUST LANDS I`E' <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DfjY$.�� ASr LRQ O rO� # TH A EA (' DAYS: NAME(LAST,FIRST) <br /> N� PHnNP WITH AREA r. <br /> H`HTS: NAME(LAS.FFI -PFO AIIIf�jE�C/Qpv`E\I NIGHTS: NAME(LAST,FIRST) <br /> 111. PROPERTY OWNER INFORMATION•(AMIUST BE COMPLETED) <br /> NAME O" (� CARE OF ADDRESS INFORMATION <br /> MAItS ORPJAADDRE b IDINICINDIVIDUALLOCAL-AGENCY ED STATEAGENCY(v TI -AGENOU aOPARTNERSHIP Q COUNTYCY <br /> FEDERAL-AGENCY <br /> CITY NAME \ l+ ,1 ZT� ZIP):QDE ��� �O�TFf1r EA LADE <br /> III. TANK OWNER INFORMATION\-(MUST BE COMPLETED) l]l RJIv 1 4 IA2— <br /> NA"FOOW'NER CARE OF ADDRESS INFORMATION <br /> MTGGOST TAD S ✓Eox bindicale <br /> O INDIVIDUAL QLOCAL-AGENCY E-1STATE-AGENCY <br /> e D CORPORATION PARTNERSHIP Q COUNTY-AGENCY O FEDERAL AGENCY <br /> CITU NAME Loh \ S� ZIP,C�O EP NOE#WITH EA CyQDE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916))323-95551f questions arise. 1F!(JI DA_� <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicate 1 SELF-INSURED 2 GUARANTEE E::] 3 INSURANCE Q 4 SURE7V BOND <br /> D 5 LETrER OF CREDIT 0 6 EXEMPTION O N 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: I.❑ I.❑ IN ❑ <br /> THIS FOR AS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> A ICA SN P E SIGNAT J AR LICAN TITLE D E MONTWDAYNEAR <br /> �Lj <br /> LOCAL AGEN Y USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# GI <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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) FOROW3A5 <br />