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a <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD( / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM AIS FORM FOR EAC CILrTYISITE <br /> MARK ONLY L] 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT O 4 AMENDED PERMIT 5 TEMPORARY SITE CLOSURE <br /> IQ <br /> I. FACILITY/SITE INFORMATION&ADDRESS- (MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS S J,NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> 3 Co I cE.e .� (�c,4-p— �� <br /> CITU NAME STATE ZIP CODE <br /> SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓ BOX <br /> TO INDICATE CORPORATION D INDIVIDUAL D PARTNERSHIP 0 AL-AGENCY D COUNTY-AGENCY <br /> DISTRICTS ID STATE-AGENCY FFDEMLAGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> Q 3 FARM 4 PROCESSOR 5 OTHER OOR TRUSTRESERLATION <br /> ANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> L/ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WIT AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADOflE1S,S ✓ box b Ndbab D INDIVIDUAL O LOCALAGENCY I� STATE- <br /> AGENCY <br /> 7 1 L! 1 ✓/,L, CORPORATN)N PARTNERSHIP �COUNTYAGEWY � FEDEMLAGENCY <br /> CITY NAME S STATE ZIP CODE PHONE#WITH AREA CODE <br /> KA q <br /> S <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> GL"Llo k S <br /> MAILING OR STREET ADDRESS ✓box bbObaN D INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> D CORPORATION = PARTNERSHIP 0 COUNTYAGENCY 0 FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV,BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. <br /> TY(TK) HO [4-J-4]-'�L' Y� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bo,bird1cm 0 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION D W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is c ed. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.I] IL 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNFAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACI�T STAN Y'f� <br /> LOCATIONCOODE -OPTIONAL CENSUS TRACT -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) <br /> /��/�J f 0033A8 <br /> � y <br />