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'l STATE OF CALIFORNIA °. <br /> S I k STATE WATER RESOURCES CONTROL BOARD i <<• <br /> ? <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� �: <br /> 1�011M�� <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OWIONAW <br /> Al S/Y S, mora <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Sjv�k CAI/ Box <br /> 9�joi <br /> TO INDICTE O CORPORATION O INDIVIDUAL D PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O t GAS STATION 2 DISTRIBUTOR [] ,/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.x(primal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> r V6 �o— <br /> NIGHTS: NAME(LAST,FIR PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE v WIE 71 <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 4.4 (&1r A61 <br /> MAILING OR STREET ADDRESS ✓boa bintlkala 0INDIVIDUAL D LOCALAGENCY Q STATE-AGENCY <br /> 0 CORPORATION = PARTNERSHIP COUNTYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S'/b C E Fv ojs Z v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> QS <br /> MAILING OR STREET ADDRESS ✓box b Wkam OINDIVIDUAL QLOCAL-AGENCY F-1STATE-AGENCY <br /> I�CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD UALIZATION UST RAG E ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) 0 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boablndk>b O I SELF-INSURED O 2 GUARANTEE 3 INSURANCE [-14 SURELY SONO <br /> O 5 IETTEROFCREDIT a EXEMPTION Q N 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 check <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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrrY# O//C/F aW <br /> 9� <br /> LOCATION CODE -OP NAL CENSUS TRACT# - 77ONAL SUPVISOR-DISTR ICT CODE -OPTIONAL <br /> 0 a s /l9/4 -2— <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS I NGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOIIlp35 <br />