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• 9 you; e <br /> STATE OF CALIFORNIA W+ <br /> STATE WATER RESOURCES CONTROL BOARD ; B <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �`� ye <br /> :n tee.. o <br /> /p �' <br /> ONN�� <br /> Imo' COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> I <br /> MARK ONLY ?I t NEW PERMIT 3 RENEWAL PERMIT O 6 CHANGE OF INFORMATION T PERMANENTLY CL <br /> ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAONAM V47 NAME OF OPERATOR <br /> ADDRESS NE ARE ST CROSSSTREET PARCEL#(OPTIONAL) <br /> v S5' o c 4- <br /> CITY NA�M,/�/� STATE ZIP CODE WITH AREA I E#WITH C <br /> CA <br /> TO INDICATE D CORPoPAT INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY O STATE AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION 0 2 DISTRIBUTORD <br /> RESERVATION <br /> INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM O 4 PROCESSOR Q 6 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ZVEIZP� � 36 -d 2 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE v WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILIN STREET ADDRdE3S/ / � ✓ box blMkaW INDIVIDUAL O LOCAL AGENCY I1 STATE-AGENCY <br /> b v�G/ZN CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STAT ZI � f)A �'Q'ITH A� Dh/ <br /> liapT J\\ v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATI <br /> MAILING pR STREET ADDRESS ✓ box blMkale INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> G// �f �F CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE ONE WITH AREA CODE <br /> GoDl �- a 2'4bF-olz <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4_1 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box biMicate 0 I SELF INSURED =1 2 GUARANTEE O 3 1NSURANCE E_1 4 SUREN BOND <br /> D 5(ETTEROFCREOIT =6 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ 11.0 111. <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) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY# / G A 7 CJl <br /> pG/C O� <br /> LOGON CODE -OPTIONAL CENS�TRACT# -OPTIONAL SUPVISObR-DISTRICT CGDE -OPTIONAL -� Z5. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> F/O�NNLY. <br /> FORM A(5-91) �LNV 000.7A-5 <br /> 0 <br />