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• 'x"eOJA t <br /> / STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e <br /> COMPLETETHIS FORM FOR <br /> EACH FACILRYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT 'p<5 <br /> Q 5 CHANGE OF INFORMATION O 7 PERMANENTLY C <br /> ONE ITEM O 2 INTERIM PERMIT O d AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D'ABA'O``R-F- ILITY NAM '`� LL � 1 <br /> NAME OF OPERATOR <br /> r GAUD (Q(/ v'N t� 7t�L�, <br /> ADDRESS / NWVkRESTCRD§S STREET PARCEL#(OPTIONAL) <br /> Zit b r E• Lcrt,c a� � <br /> Vni <br /> CI N ME CODE ITE PHONE#WITH AREA CODE <br /> Gu Ca 5336 ;ITE <br /> s2S-77Zov <br /> I/ BOX <br /> TO INDICATE CORPORATION Q INDIVIDUAL 0 PARTNERSHIP ;!�OCAI.AGENCY E–1 COUNTY AGENCY STATE AGENCY Q FEDERAL-A ENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O / GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#Inplional) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR X 5 OTHER OR TRUST LANDS jf <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAkNy AST,FpT) AREA CODE DAYS: NAME(LAST,FIRST) <br /> .; O yZ�15?2&v <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA COD] <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA E M r' , eSi�k \ �� c CARE OF ADDRESS INFORMATION <br /> MAILING OR STR ET ADDRESS•l ✓box blMicma D INDIVIDUAL Z LOCAL-AGENCY O STATE-p CY <br /> Px O • CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY Q FEDERALAGENCY <br /> CITU AME ST ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA F OWNf R5�_ CARE OF ADDRESS INFORMATION <br /> &IA .PQ t C1 i` t 1 <br /> MAILING OR STREET ADDRESS %/ box b IndIcale INDIVIDUAL j5d'LOCAL-AGENCY QSTATE A Cy <br /> CORPORATION Ej PARTNERSHIP (] COUNTY-AGENCY FEDERALAGENCY <br /> CITU NAME LI- STA ZIP C DE P.H�ONNE##�ITH 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 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b lndlcale 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE 0#SURETY ND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION Q W 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRE S SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.El II,�?l In E <br /> THIS FORM HAPS BEEN COMPLET UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> AJICA AM (PRE IN EDUIGNAT RE) A PLICANTS TIT DATE MONTWDAYIYEAR <br /> /// /�c Lou vL �L/tJt —9 <br /> LOCAL AGENCY USE ONLY B <br /> COUNTY# JURISDICTION# # <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR�DISTRIC BOE -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) FOR0033A 5 <br /> 3-a0- 4 7 A°� <br />