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y JP <br /> STATE OF CALIFORNIA v <br /> STATE WATER RESOURCES CONTROL BOARD ttP <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAQP1ACILrrVSrrE <br /> MARK ONLY r7 1 NEW PERMIT 3 RENEWAL PERMITCHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ t INTERIM PERMIT 4 AMENDED PEflM1T S TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF NAME OF OPERATOR <br /> ADDRESSp NEAREST CROSS STREET PARCEL#(OPTONAU <br /> 3 PdS <br /> CITU STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓ <br /> CA 457 Z_oz:x— <br /> TO IMOCATE—M MIPOBAM 4OIWUAL PMITSERaN► Q LOTRICTSACY Q COUNTY [] STATE-AGENCY I� FEDEFIALAGENCY <br /> TYPE OF SUSM 17 ITOR .1IF INDIAN 10 OF TANKS AT SITE E.P.A L D.#roptmap <br /> l /-A. _ _ RESERVATION <br /> (� GC j/ � BOR 5 OTHER OR TRUST LANDS <br /> ARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: ATH AREA CODE q DAYS: NAME(LAST,FIRST) <br /> L <br /> ')y / �3—co)( SQ ft. Punu9a M TW eace rnnF <br /> N S: NAME VITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE f WITH 6FFG fllhF <br /> II. PROPE.... ...... ..... .. .. ... . BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �Lc S / <br /> MAILING OR STREET ADDRESS ✓ hw bbtlbale E�:] INDIVIDUAL LOCAL-AGENCY Q STATE AGENCY <br /> 0 CORPORATION = PARTNERSHIP O COUNTYAGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILNG 09 STREET ADDRESS,- bmf 0Wdc A I= INDIVIDUAL LOCAL-AGENCY U STATE AGENCY <br /> (�CORPORATION Q PARTNERSHIP Q COUNrYAGENCY FEDERAL AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD C EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 14F4]- <br /> V. <br /> 4 4 -V. PETROLEUM UST FINANCIA SPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box binEkale I SELFINSURED Q R GUARANTEE 3 INSURANCE A SURETY BOND <br /> = 5 LETTER OF CREDIT O S EXEMPTION 0 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boy I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 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 B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3`9 e <br /> LOGiTMCODE -OPTIONAL CENSUSTRACTa -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3 A 37, S- C-D l f3 <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(12-9I) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM31A FE <br />