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STATEOFCAUFO&VASTATE WATER RESOURCES <br /> OL <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT <br /> a Ga�•o�w,.'o' <br /> ONE R 2 INTERIM PERMIT <br /> EM ❑ S RENEWAL PERMIT ❑ S CHANGE OF INFORMATION <br /> ❑ ❑ 0 AMENDED PERMIT ❑ T PERMANENTLY CLOSED SITE <br /> I. FACILITYISITE INFORMATION&ADD, ❑ S TEMPORARY SITE CLOSURE <br /> "ME R FACILITY NE ESS-(MUST BE COMPLETED) <br /> ESS — 70 NAME OF OPERATOR <br /> ADDR�ES�S., <br /> go � ' �/ �j�� :` NEARESTCROSS STRECITYET PARCEIi(OPfONALI <br /> V STATE ZIP CIO <br /> ✓BOX <br /> CA SITE PHONE i WITH AREA CODE <br /> TO INDICATE O CORPORATION (]INDIVIDUAL Q PARTNRSHIP 0 LOCAL,, <br /> •H Amer d UST IB A PUbrc Aeincy,ogRpllle V*' DLSTRCTS I OW <br /> CMY-AGENCY' O STATE-AGENCY, Q FFDEML#OENCy, <br /> TYPE <br /> o ft'name of SUPONI6or of division,w0on,or office Which OPWmm the UST <br /> OF BUSINESS O f GAS STATION Q 2 DISTRIBUTOR <br /> 3 FARM ✓ IF INDIAN 8 O TANKS AT SITE E.P.A, I. <br /> OR <br /> D.i <br /> ❑ ❑ 6 PROCESSOR 5 OTHER RESERVATION roWknAe <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY).aptlonN <br /> DAYS:NAME(LAST,FIT) PONE WITHAREACODE <br /> DAYS: NAME(LAST,FIRST) <br /> � PHONE=AREA:C0DE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTSNAME(LAST,FIRST) PHONE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME <br /> �t�� � CARE OF ADDRESS INFORMATION <br /> /w✓A-iLL_. !?C� c /�Tyr Ams <br /> MAILING OR STREET ADDRREE'SS ✓Eoa bNgkati INDIVOIIAL LOCAL AGENCY STATE AGENCY <br /> 0' ('JO CORPORATION PARTNERSHIP Q COUNTYAGENCY [:jFEDERALAGENCY <br /> CITY NAME ATE ZIP CODE P NE i WITH AREA CODE <br /> gr <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADORESS INFORMATION <br /> MAILING OR STR ADDRESS -70g ✓ bcablrAbau = INDIVIDUAL Q LOCAL-AGENCY M STATE-AGENCY <br /> r Q, J 4KCORPORATION = PARTNERSHIP 0 COUNTYAGENCY E-1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE A WITH AREA CODE <br /> 9 6o i -46rL <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 R-10 19 119 W <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ Eoa blMicala O 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE (]A SURETY BOND <br /> O 5 LETTEROFCREDIT O S EXEMPTION O m OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 its checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.Ill III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED S SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY �'!�Y o <br /> COUNTY# JURISDICTION FACILITY# o ,v O <br /> 17,131119 ii 1;:�i <br /> LOCATION OODE -OPTIONAL —12—Tr <br /> ENSUS TRACT# -OPTIONAL 9UPVISOR>-DISTRICT CODE -OPTIOWAI. <br /> L ' � <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS -- �GRotn>Am <br /> FORM A($93) -..r <br /> s <br />