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• ecoue <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �el,f OXYf <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ; J <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> inc F Rab 12 ti• 30_ jr <br /> ADDRESS <br /> .•s NEARESTCROSS STREET PARCELa(OFTIONAL) <br /> xep7�/.x0 w. T jitimc acl -ros c 12oaol .238 - 6a0 - 06 <br /> CITY NAME STATE ZIP CODE SITE PHONE M WITH AREA CODE <br /> ?reLc CA 953 6 3 <br /> TO INDICATE O CORPORATION E-1 INDIVIDUAL X PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS X 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN x OF TA KS A SITE E.P.A. I.D.x(optimal)RESERVATION �f <br /> ❑ 3 FARM 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS G OO�� pp S6 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY C TACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> MS) 3YS- oo APHONP A WITH AREA MDF <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> sa 2p /s)36 - L66PHONE 9 WrTH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> O$ c Z R. OG TOSfC <br /> MAILING OR STREET ADDRESS ✓ box blWiwle Q INDIVIDUAL O LOCALAGENCY 0 STATE-AGENCY <br /> '-2 ,/80 TOS C b CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE%WITH AREA CODE <br /> TraCY C/9 9S-3 7-L ! o Sas-�s99 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /"P- 7-or- as fc <br /> MAILING OR STREET ADDRESS ✓ box bindbale Q INDIVIDUAL D LOCAL-AGENCY O STATE-AGENCY <br /> a y 8 o ?O$& deoevalCORPORATION O PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE <br /> Tra c y 64 ?5,39­ ,6 ? BsS- 6599 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 0 3 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE � 4 SURETY BO1ND <br /> S <br /> 05 LETTEROFCREDrr O6 EXEMPTION CK 99 OTHER =V% Y-a v, PC <br /> CilijiA <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 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 /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> ��� P y/ao/ 93 <br /> CAL AGENCY USE ONLY <br /> 1 uj'COUNTY# JURISDICTION <br /> 2 / lti i <br /> LOCATION CODE -OPUS TflACT• -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> S <br /> THIS FORM MUST BE ACCOMPANIED 13Y AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORD033A 5 <br /> r <br /> 3qQ3 0 <br />