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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD iu <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A m� ys <br /> b, . <br /> COMPLETE THIS FORM F EACH F LITYISRE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ANGE OF INFORMATION ❑ 7 PER ENTU ED SREy <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 WENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBAORFACIUTYN ENAME OF OPERATOR <br /> ADDRESS NEAREST SS TREET PARCEL I(OPTONAL) <br /> I 1Z1 -1 5 . wa <br /> CITY NAME STATE ZIPS PMONE A WITH AREA DE <br /> S CA Slob 6 <br /> TO INDICATE.1 Box O CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY CD OOUNTV-AGENCY Q STATE-AGENCY CD FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 5 GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN Y OF TANKS AT SITE E.P.A L D.S(bpfiolYl <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N E(LAST,FIRST) PHQNE S XVITH AREA C <br /> DAYS: NAME(UST,FIRST) <br /> NIGHTS: NAME(LAST,FIR PHONESAMTH AREACODE NIGHTS: NAME(LAST.FIRST) PHONE 0 WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME , CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES ✓ b"b"cM1 ED INDIVIDUAL 0 LOCAL-AGENCY Q STATE-AGENCY <br /> Lr (^ 1,J-TM/U O CORPORATION 0 PARTNERSRP Q coUNTYAGENcY E3 FEDERAL,IGENCY <br /> CITY NAME8TATF. 21P CO PNIXJE S WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) /✓IJ�s— 9' <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ wxmmb I= INDIVIDUAL Q LOCAL AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP Q COUNrY#GENCY a FEDEFALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAgE FEE ACCOUNT NUMBER•Call(916)323-9555 If questions arise. <br /> TY(TK) HQ 4 4 A <br /> -�A b I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ b intlbm Q 1 SELF-INSURED O 2 GUARANTEE 5 INSURANCE 0 /SURETY BONG <br /> O 5 LErTEROFCREW a 6 EXEMPTION 99 OTHER <br /> Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.IV <br /> II.= IN. <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 b SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> =6—2 2— <br /> LOCAL <br /> LOCAL AGENCY USE ONLY z <br /> COUNTY III r3r )l�"L I JURISDICTION <br /> LJ—L— u 3 a 01 AlLITY s 6 <br /> LOCATION CODE -OPIT�ION�AALFII CENSUS TRACT -OPTIONAL L_J—L—, SUPVIS -DISTRICT CODE -OPTIONAL <br /> olf <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) GCRaa1JA5 <br />