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L <br /> STATE OF CAUFOf MA •• <br /> \ / STATE WATER RESOURCES CONTROL BOARD <br /> \\} / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> ry <br /> COMPLETE THIS FORM FOR EACH FACILRYISITIF <br /> MARK ONLY Q I NEW PERMIT F7 5 RENEWAL PERMIT IY 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2IN�eRIM PERMIT Q A AMENDED PERMIT a TEMPORARY SITE CLOSURE !>'� <br /> I. FACILITY/SITE INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME //`` / NAME OF OPERATOR / <br /> C! L�c �i f 11 6v 11 <br /> ADDRESS EARESTCROSS STREET PARCEL A IOFTGNAU <br /> DYY S . ALAtc.>e-�k I-rJe o <br /> DUTY NAME STATE LP CODE SITE PHONE A WITH AREA CODE <br /> S�Gc /�1TM CA �fsZoT - Sia <br /> TO DCCAATE Q CORPORATION Q nalvauAl Q PAIRNERSHP LOCALAGENCYQ CdINIY AGENCY QSTATE-AGENCY Q FMEPALJGENCY <br /> o6TRICTS <br /> TYPE OF BUSINESS Q 1 OAS STATION Q 2 DISTRIBUTOR0 pESERVADw <br /> / tw <br /> •OF TANKS AT SITE E.P.A. L D.s(goW) <br /> Q O FARM Q ♦ PROCESSOR 5 0:E OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA COOS DAYS: NAME(LAST,FIRST) <br /> S-Au / 20 Le(06- 35�� <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> o ACCnq <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING ON STREET ADDRESS = INDIVIDUAL Q LOCALUGENCY Q STATEM,FNCY <br /> 191 <br /> C /L(6 y Q CORPOMTXNI Q PARTNERSW Q COUKn+GENCY Q FMERALAGENCV <br /> CITY NAME STATE I ZIP CODE I PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> ,NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ tmororaM Q INDIVIDUAL Q IOCALAGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEOERMAGENCY <br /> CITY NAME STATE ZIP CODE PHONE A WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ74 74 - O 1 3 .2 V57a1 L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METH00(S) USED <br /> ✓5m ovlanr Q I SEwNSURED Cj 2 GUARANTEE Q 1 NSURANCE Q A SuREn am <br /> Q 5 LSTTFROFCREDT Q L EXEISTON Q 9e 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 /> CHECK ONE BOX INOICATINO WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING L= 1L= ILL <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) APPIAANT9 TITLE DATE MONTNDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION X FACILITY a <br /> Ll loz I s4o 4C Lq40 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONALC <br /> 3'P0 1 393 1=419i Go d <br /> THIS FORM MUST BE ACCOMPANIED BY AT LF"-T(T)OR MORE PERMIT APPLICATION- FORM 8,UNLESC THIS IS A CHANGE OF SITE INFORMATION ONLY./ <br /> FORK A(Set) - //' / Ftl10m1Ad <br /> �" I I <br />