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v <br /> STATE OF CALIFORMA :� <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A -�� ;s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `�l,/Un"" <br /> MARK ONLY I NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED <br /> ONE REN ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE O , <br /> 7t <br /> I. FACILRYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> M�qR FACILITY N NAME OF OPERATOR <br /> 1 0 C1 <br /> ADDRESS NEAREST CROSS STREET PARCELO(OPHONA4 <br /> CITVN STATE ZIP CODE SITE PHONE O WITH AREA CODE <br /> CA <br /> T / BoxTE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY I1 COUNTY.AGENCY' O STATE-AGENCY' O FEDERALAGENCY' <br /> DISTRICTS' <br /> 'X Amer d UST M a pubic pang,complete the folowing:name of Supsmew of division,section,w office which operates the UST <br /> TYPE OF BUSINESS 0 t GAS STATION 0 2 DISTRIBUTOR 0OR ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.0(optica) <br /> RESERVATION <br /> 0 3 FARM E:] 4 PROCESSOR 0 5 OTHER TRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE 0 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Oos bYlectls OINDNNIML OLOCAL-AGENCY O STATE AGENCY <br /> O CORPORATION O PNITNERSHP 0 COUNTY-AGENCY =FEDERAL-AGENCY <br /> CITY NAME YRVATM <br /> ODE PHONE 0 WITH AREA CODE <br /> III ANK OWE" ' ' ..,tet ec rAt ETE <br /> N EOF OWNER PACIFIC BELL-PERIvUr DESK INFORMATIONP. O.BOX 15038 M LING OflSTREET CD INOIVIOUAL LOCAL-AGENCY 0STATE-AGENCY <br /> 2646 WATT AVENUE, SUITE 40 PARTNFASHIP O CWNTY#GENCY O FF3 EMLAGENCY <br /> C ME SACRAMENTO, CALIFORNIA 9585 •(ADE PHONE O WITH AREA CODE <br /> ATTENTION: LOUANA J. URIBE <br /> IV.BOAR LIZATION UST STORAGE rtI A(:CO )322.9669 if questions arise. <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ooc toIdkWe O I SELF-INSURED 0 2 GUARANTEE 0 S INSURANCE 0 4 SURETY BOND <br /> O 5 IETTERGFCREDIT 0 5 EXEMPTION = go OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless b(TX I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED IN SIGNED) OWNERSTITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY 0-1N S <br /> COUNTY <br /> 0 JURISDCTION• FACILITY i <br /> LOCATION CODE -OPTpNAL CENSUSTrA OPgr � 9UWISOR-DISTRICT CODE •OP� <br /> THIS FOhM LIUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS 6 A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UND{�F� ROUND STORAGE TANK REGULATIONS <br /> FORMAISM) j 7,y�� FaRm�aT <br /> kTb <br />