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STATE OF CALIFORNIAy' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> C�t1IOnM�- <br /> COMPLETE THE FORM FOR EACHFACILITYISTTE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT 0 e CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE FTEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> of OPERATOR <br /> qRA OR FACILITY N�P�/yE <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) — <br /> rADDRESS 4k _ �� <br /> Ab STATE Z19COD�F Q�� SITE RIONE#W NTH AREA CODE <br /> AMEt✓ Box (]CORTORATM 0 INDIVIDUAL 0 PARTNERSHIP (] LOUAL-ta�YO COUNTY-AGENCY' 0 STATEAGENCYFEDEFAL#GENCY' <br /> OINDICATE DISTRICTS'er d USi la a public a3eney,000pide IM lo2owlnB:name d Superv4or d dN4bn,section,m of ioe which operates the UST OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.i(optmMq <br /> RESERVATION <br /> Q 3 FARM 4 PROCESSOR Q S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) <br /> PHONE#WITH AREA CODE DAYS:NAME(LAST,FIRST( PHONE s WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LABT,FIRST) PHONE#WITH AREA CODE <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> �ILIW-rs <br /> APvBuL u-GlMERSbMbNdk#s 0 INDIVIDUAL 0 LOCAL-AGENCY D STATE'AC£NCY <br /> O CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERALAGENCY <br /> GTY NAME 8TA7& ZIP PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) `rj(_ <br /> I/ 7/ 3 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S.T- GE OESSar cY O�Bwc svc�� <br /> MAILING OR STREET ADDRESS ✓Gov b � D INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> CGRPORATHON 0 PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGEWY <br /> � �O 0 - _ STATE LP CODE PHONE#WITH AREA CODE <br /> CITU NAME <br /> 4 -7-_5 <br /> _52,01 <br /> Tp o C47 `71J0 . <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> bob Wdicee 0 1 SELF-INSURED D 2 GUARANTEE O 3 INSURANCE O X SURETY BOND <br /> O 5 LETTEROFCREDIT Q 6 EXEMPTION O 69 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: 1.0 11.a III.L I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDK:TION# FACILITY# _ <br /> ® ) -7 o 3 L? 6 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SLI DISTRICT CODE -OPTIONAL <br /> ZS. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE ONL . <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAMW <br /> FORM A(M FORIXIMA417 <br />