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• • remaoa es <br /> STATE OF CALIFORNIA r o <br /> STATE WATER RESOURCES CONTROL BOARDr <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <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 C— <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 4tF J`) <br /> V <br /> DB OVVI ILITY&Er ST , 4 ` ,J NAME OF OPERATOR <br /> l//U4,,�t�`LL�. ST <br /> ADDRESS 1 ••,, j fjApESTOS TREET PARCEL#(OPTIONAL) <br /> LINvLQ �K ` IkAA1 uv- f�ry <br /> CITY NAME STATE ZIPCODE SITE PHONE#WITH AREA CODE <br /> �r Ca S <br /> ✓ Box <br /> TO INDICATE F-1 CORPORATION (]INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. <br /> I.D.#(optimall <br /> Q 3 FARM O 4 PROCESSOR EN 5 OTHER OR TRUST LANDS ! e A d n f uS -75'7— <br /> EMERGENCY <br /> /J7- <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> VS NAME(LAST,FIRST) PHOE#WITH REA COOE DAYS: NAME(LAST,FIRST) <br /> lnle�seu e� l�Au� <br /> NIGHTS: NAME(LAST,FIRST) 11 P ON7E�#�pWT.FIRST) <br /> WITH AREA CODE NIGHTS: NAME(L <br /> b;� t/ <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 6 / CARE OF ADDRESS INFORMATION <br /> MAILING OR STTWEEYox 0lntlicat l�T ADDRESS ✓bINDIVIDUAL LOCAL-AGENCY Q STATE AGENCY <br /> P'p , ,d✓x7Aj O CORPORATION 1 PARTNERSHIP E71COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME STA 21P DE H(so,) <br /> oWITH AREA CODE <br /> " <br /> q(.7 0 <br /> willl.. TANK WNER INFORMATION-(MUST BE COMPLETED) Lt 'rl Up7#S <br /> NAMEOFOWI+1R &�� ? � . �)14 CARE OF ADDRESS INFORMATION <br /> MAILING OR STRUTAA�D`yDRESlS�, Jjw,T• Y ✓ boi blydiwle = INDIVIDUAL [LOCAL-AGENCY STATE-AGENCY <br /> t `�• IOL,/(( �l OCORPORATION OPPARRTNERSHIP 000OUNTTYl AGENCY OFEDERALAGENCY <br /> CITY NAME <br /> SZ Z�F7 ! [,PHONE WITH ARE <br /> rraH ' <br /> IV. BOARD bF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F41 4 -Lj]7=D:—,, <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box 0irdicau 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CR EDIT D 6 EXEMPTION Q W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank 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.❑ IIX III.❑ <br /> THIS FORM HAS BEEN COMPLET UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> A LICNT'S NNAE(PRUO&SIGN E �LIGANPS TI �� DATE 2,MONTWDAYNEAR <br /> #/ILL/,,�t/I♦�I L LN�rC l' -'n? <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrTY# (p <br /> m <br /> LOCATION CODE -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) FORW33A 5 <br />