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11I.a" ../ <br /> STATE OFCALIFORMA <br /> STATE WATER RESOURCES CONTROL 1016111 3y <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Y� p+ <br /> p.bpn. <br /> COMPLETE THIS FORM FOR EACH FACICrTYISITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 52 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAMEOFOPERATOR <br /> O h.hPLI SG 3 S 6? <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3d C!(cYG4� <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> a CA <br /> I/ Box <br /> TO INDICATE a CORPORATION D INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY O FEDERAL-AGENCY <br /> DSTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE/ IF INDIAN SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE o WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 'L -s -1r3 s4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> SccµP srz .+O #Wl�AREA COG <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET DRESS ✓ EwbinOicaG 0 INDIVIDUAL 0 LOCAL-AGENCY ED STATE-AGENCY <br /> /V, - 0 CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> 0 9S3(m,G -a/3 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Sq AV G 5 <br /> MAILING OR STREET ADDRESS ✓ EEa binakau [:3 INDIVIDUAL 0 LOCAL AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE It WITH AREA CODE <br /> IV.BO F EQUALIZATION U FEE ACCOUNT NUMBER •Call(916)323.9555 if questions arise. <br /> K) HO 4 4 pz d' <br /> V. PETRO CIALRESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFYTHEM OD(S) USED <br /> ✓ Eat biMkals 0 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY 90NO <br /> D 5 LETTEROFCREDiT O 6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 10`s checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. IL❑ IN.❑ <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY _ ------- <br /> COUNTY# JURISDICTION# FACILITY# R/PO.1l <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE - <br /> a � �\ <br /> q1 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 /> 1 FORM A(5-91) FORD033A.5 <br />