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STATE OF CALIFORNIA 'ezo�X <br /> / STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A g e <br /> 41sOXX X <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT KL 5 CHANGE OF INFORMATION [--] 7 PERMANENT C SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FAC ITV NAMEO NAME OSv.IrV Yo <br /> 11+�QN SL yL <br /> ADDRESS NEAREST CROSS STREET PARCELp(OPTIONAy <br /> So f3 W. {-�.✓ W <br /> CITY NAME rU STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Sh CAI/ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY O STATE AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS fIID 1 GAS STATION 2 DISTRIBUTOR IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> L!� RESERVA 10 — .- <br /> 3 O d PROCESSOR Q 5 OTHER OR TRUST LANDS 7 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> AVS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,TFIRST) - -�C, _ q(.5- �,/L�O <br /> Sitio — 5-3' O �i k YQNAA I `aT <br /> t d <br /> NIGHTS' T,F� ST) ( E#WITH AREA CODE NIGHTS: N ME L T,FIRST) OZ <br /> � IN.Fr iA-A Q.✓ —O <br /> IL PROPE TY 0 ION- MUST BE COMPLE <br /> NAME l CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDDR'ESS1 1 1 f ✓ boxblMkale INDIVIDUA 0 LOCAL-AGENCY O STATE-AGENCY <br /> 11 S IvL'*Q-✓ S+- O CORPORATION Q PART SHIP ] COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY STATE ZIP COD PHONE#WITH AREA CODE <br /> S-2-0 <br /> III. T -OWNER INFORMATION (MUST BE COMPLETED) <br /> I MINER <br /> CARE OF ADDRESS RMATION <br /> LISTra <br /> NG ORREET ADDRVS <br /> ✓ box 0indicate 0 INDIVIOU 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> ORPORATION E-1 PARTNERSHI (] COUNTY AGENCY FEDERAL-AGENCY <br /> C NAME TATE ZIP C DE !�Z PHONE#WITH AREA CODE <br /> A.Anf_`X' vs-6i 5(O — S 2 — $S'a O <br /> IV. B D OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if que ons arise. <br /> TY(TK) HQ 4 - <br /> V. <br /> -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindlcate 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURA A SURETY BOND <br /> D 5 LETTER OF CREDIT 0 6 EXEMPTION I= 99 ER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS 4egal notification and billing will be sent to the ank owner unless box or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE U D F LEGAL NOTIFICATIONS AND BILLING: I. � II III. <br /> THIS FORM HAS BEEN CO UNDE PE&TOF P URY,AND TO THE BEST OF MY KNOWL GE,IS TRUE AN CORRECT <br /> APPLICANTS NAME(PRINTEDB SIG TURE), APPLICANTS TITL O MONTWDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURI DICTION# FACILITY#131 ( JI:T] <br /> ��� <br /> LOCATION CGDE -OPTIONAL UhNbUS TRACT -OPTIONAL SUPYOR-01ST ICT 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 RM N ONLY. <br /> FORM A(5-91) <br /> • Fg10679A-5 v <br />