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• STATE OF CALIFORNIA • ,<spU" ° <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A "moo <br /> G COMPLETE THIS FORM FOR EACH FACILITY/SITE .°""'°""'• <br /> MONS IARK TEM 1 NEW PERMIT 3 RENEWAL PERMIT a CHANGE OF INFORMATION ] PERMANENTLY CL D SITE <br /> 2 INTERIM PERMIT O 4 AMENDED PERMIT L] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> FADDRESS <br /> r �r G w NAME OFOPERATOR <br /> j' / �,( NEAREST CROSS STREET PARCEL (OP IONAL)STATZIPCODE SITE PHONE R WITHA EcA4 G 4 �CORPORATION 1711 INDIVIDUAL 0 PARTNERSHIP (] LOCAL-AGENCY 0 COUNTY-AGENCYQ STATE-AGENCY <br /> DISTHICTS � FEDERAL-AGENCY <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. <br /> 3 FARM d PROCESSOR7REq RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME�(LAST,FIRST) _ HONER WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> /moi V xwv 10 <br /> NIGHTS: NAME(LAST,FIRST) PHONER WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PH <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> _ Gl/ Tull /e•/J ,4 v <br /> MAILING OR STREET DRESS ✓ box b IndicalR <br /> Q INDIVIDUAL L::] LOCAL AGENCV El STATE-AGENCY <br /> CITY NA O [I]CORPORATION Q PARTNERSHIP =COUNTY-AGENCY Q FEDERALAGENCY <br /> Gvv <br /> STATE ZIP CODE PHONE#WITH AREA CODP <br /> c�� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNE <br /> _I - _ `_- CARE OF ADDRESS INFORMATION <br /> MAILING UK STREET ADDRESS• I <br /> � ✓ box b im1cale <br /> I� <br /> /v L A ,Pv Q INDIVIDUAL LOCAbAGENCV STATE AGENCY <br /> CI NAME' G• #�. /•7 L CORPORATION PARTNERSHIP I] COUNTY-AGENCY FEDERAL-AGENCY <br /> �D STATE ZI��� PHONE#WITH AREA DE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4 4 -[:j_f:]�= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindicale = I SELF INSURED 0 2 GUARANTEE [_1 3 INSURANCE <br /> CI 5 LETTEROFCREDIi 6 EXEMPTION O A SURETY BOND <br /> 59 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.❑ 11.0 III.O <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 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> "2i FACILITY# <br /> LOCATION CODE -OP TION1 (CENSUS TRACT -OPTIONAL 1--�-__ _aPVISOR QISTRJCTCOOE_�GPT1ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(7)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATION,$ <br /> • FOR0033A R6 <br />