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c <br /> STATE OF CALIFORNIA '' <br /> STATE WATER RESOURCES CONTROL BOARD #ym�, ,n a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> (see NeAA b,If1A� Mess • ,.oro;.. <br /> COMPLETE THIS FORM FOR rAFACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 ( <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME t NAME OF OPERATOR y <br /> ?M( ✓/a Fro.J elntbutsf /ON eIvT f/ - <br /> ADDRESS NEAREST CR STREET PARCEL#(OWIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITHAREA CODE <br /> Sloe aba CA 4sx1: b <br /> TO Box CORPORATION f� INDIVIDUAL PARTNERSHIP f�LO p�GENCY 0 COUNTYAGENCY O STATE-AGENCY 3/FEDERAL-AGENCY <br /> TS <br /> TYPE OF BUSINESS O ) GAS STATION ❑ 2 DISTRIBUTOR -/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE IN WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> $'o,Jcfoo aiN laa #z. s <br /> MAILING OR STREETADO SS ✓bol DWeare D INDIVIDUAL 0 LOCAL-AGENCY QSTATE-AGENCY <br /> W (+ S't' D CORPORATION L-1 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME 9-16,c k4o,4 STATE ZIP CQS 2p 1— PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) Cl7 C� <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> FAA A60F l6q. 10A AHm 1� , <br /> MAILING OR STREET ADDRESS ✓ Wx bindkale D INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> P 0. pyo -te Q CORPORATION 0 PARTNERSHIP O COUNTY'AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> as eks G4 0007 3!0 -297-/i <br /> N. BOARD 0 EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F414 -1013 e2 (3 6 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bm lo,Mintl 1 SELF-INSURED E:12 GUARANTEE [] 3 1NSURANCE O 4 SURF BONG <br /> 5 LETTER OF CREDIT =6 EXEMPTION 99 OTHER <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: L❑ II.❑ 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILFTY# <br /> ® I 6 Iq I I I FAASIC o I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z s. 3zss //x 7 z <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORD033AA55 <br />