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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD f4 '` ~"'� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� y a <br /> °•<oon <br /> COMPLETE THIS FORM FOR EACH FA ITYlSITE <br /> MARK ONLY I NEW PERMIT F7 D RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE S_} <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> 03A OR FACILITY NAME NAME OF OPERATOR SA <br /> ADDRESS EAREST CROSS STREET PARCEL!(OPTIONAL) <br /> DV L( S - A( tilvl—rL Je u <br /> CITY NAME STATE ZIP CODE SITE PHONE 4 WITH AREA CODE <br /> 34� C-lA--7V" CA �frLOS- — ?S 3D <br /> TO Box Q CORPORATION Q INDIVIDUAL Q PARTNERSHP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS a I GAS STATION Q 2 DISTRIBUTOR / Q q SERVATDION a OF TANKS AT SITE E.P.A. I.D.a(oprivW) <br /> Q D FARM Q 4 PROCESSOR o f 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME RAST,FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> SLu / 2pq-Yro6- 3S3� <br /> NIGHTS: NAME(LAST,fIR511 PHONE 4 WITH AREA CODE NIGHTS: NAME(LAST,fIR4T) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AMSS ✓ EwnnNOM Q INDNOUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> C /L{6 L./ Q CORPORATION Q PARTNERSHP Q COUNTY AGENCY Q FEDERALAGENCY <br /> CITY NAME I STATE ZIP CODE PHONE 4 WITH AREA CODE <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ tmtm M Q INDIVIDUAL Q WMAGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHP Q COuNrYAGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZOP CODE PHONE 4 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 44 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J�bil6riY Q I SEWNSURED 0 2 GUARANTEE Q 5 INSURANCE Q 4 SURETY SONO <br /> 0 5 LETTER OF CREDIT Q 5 EXEMPMON Q gg OTIER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L I] IL[D 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 6 SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 4 JURISDICTION a FACILITY N A4c=rfrp <br /> S 1 4 �� '�C 1 �� `� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT4 -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> / 3� I 3 3 *J419.>— Co <br /> 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 /> FORM A(Sgp / / FpiW11A5 <br /> Y <br />