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1 STATE OF CALIFORNIA 4 <br /> STATE WATER RESOURCES CONTROL BOARD 1r�° �' •�,.�+g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> - MARK ONLY I NEW PERMIT �7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ED 7 PERMANENTLY C.C�ZJ SITE <br /> ONE ITEM a 2 INTERIM PERM:T ::3 A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> IG �i <br /> r aDDRESs NEAREST LRC55 STREET PARCEL,(OPTIONAL) <br /> LITY 'AME STATE ZIP CODE SITE PHONE,WIT):AREA CGDE <br /> 'al�L CA <br /> ✓ ez <br /> TOWDICATE :C�FPJR4TION ` �l"i:1: �'j PARTNERSKP (]LOCAL-AGENCY Cj' COULTY.AGENCY 0 STATE-AGENCY — 7:nL4GENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION 2 -S T RIBUTCR ` O ✓ IF INO:AN •OF TAtiKS AT SITE E.P.A. <br /> �]['� RESERVATION I.. <br /> r = 3 FARM — < =ROCESSCR L S OTHER OR TRUST LANDS -two <br /> v y o <br /> EMERGENCY CONTACT FE-NS.N (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•oPSoaal <br /> DAYS: NAME(LAST,FIRST) ---%E A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> , <br /> czt, � 51.D• 02'5•fir SAMA PHONE.jy,:mARUC <br /> NIGHTS- NAME(L T,FIRST) ---cE•WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION•(MUST BE COMPLETED <br /> t:Al✓.E CARE OF FD-DRESS INFORMATION <br /> 1= 10:.AUAGENGY <br /> MAILING CR STREET ADDRESS' 1 f.p, N�`7�' 13 I ✓ bw cin;aa �T "DWOUAL _ .-A3ENCY <br /> Y..I O G �IIvy , �, I I.12o I CORPORATION C FASTNERSHIP 0 COVNTYAGEI.Y _ 'E:ERAUAGENCY <br /> CITY NAME SUTE 1 ZIP CO0. PHONE•WITH AREA"_` <br /> 5 5hD 5o2S <br /> III. TANK OWNER INFORMATION•(DUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADD;-ESS INFORMATION <br /> A. MAILING CA STREET AD.-.RESS (y¢ ✓ ba�bim<cA i- INYVOUAL i., LOCALAGENCY — S-ATE AGENCY <br /> CIAOD. &O 'et 7 I ORYRATI:N =1FARTNERSHIP COUh7Y.ASENCY — iZ-94L AGENCY <br /> ST TE 2.F CODE PHONE•V."H AREA CC <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3223-9555 if questions arise. <br /> TY(TK) HO K4]-0 -ji I I jI <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓butmiwu ELFAS.=ED _3 GCRAANTEE _ i INSURANCE � 'S,:+ETV 6ON0 <br /> 5 LETIE-.0 =EDT 6 EX'MFTICN 1-7 93 CTHEA <br /> Y.N <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Leoal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE Box INDICATING WHICH ABOVE ADO ESS S�Ol;:O BE USED FOR LEGAL NOTIFICATIONS AND Br LNG: I. n. 11. <br /> r THIS FORM HAS BEEN COMPLET I7IJDER PIF LTY OF PERJUn Y,AND TO THE REST OF M.Y KNO'✓✓LEDGE,IS TRUE AND CORRECT <br /> - AFFLICANT'SNAME(PRIh'ED&E�GNATURi) A ^- AFF;-CAN IS TITLE CATE I.!C%7R0AY.YEA+ <br /> ., 15 LJ64k, <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION a FACILITY# <br /> r m LTJ <br /> LOCATION CODE a OPTIONAL iCENSUSTRACT/ -OPTIONAL SUPVISOR-DISTRICT CODE OPTIONAL <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(5 91) FORGM3A 5 <br />