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aaouX X <br /> STATE OF CALIFORNIA �`^ <br /> STATE WATER RESOURCES CONTROL BOARD 3�., <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> CXx�XOXX�X <br /> COMPLETE THIS FORM FOR EACH F CILRYISITE <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> v <br /> ADDRESS� NEAREST CROSS STREET PARCEL#(OWIONAL) <br /> CITY NAME STATE ZI ITE PHQNE#WITH AREA CODE <br /> CAI/ BOX <br /> J Z�C7 1 <br /> TO INDICATE O CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY AGENCY 0 STATE-AGENCY [-I FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aplional) <br /> O <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) HONE# TH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Off/ 4v_ /'End ' 7w) 6�- /�_//7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> xff,7->,r, 4.7A—"—zr /- <br /> �i`--L � —cxv �l <br /> MAIIUNNGOOR STREET ADDRESS L ✓ box binkalci O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> P C> /]c)x /z/ <br /> y 7 0 CORPORATION = PARTNERSHIP COUNTY AGENCY Q FEDERAL-AGENCY <br /> CITYNAME STATE ZI�DE ONE x WITH AgEA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEW OWNER CARE OF ADDRESS INFORMATION <br /> L?_�) <br /> MAIL IINN�G OR STREET ADD RESS ✓ box bindicaN 0 INDIVIDUAL 0 LOCAL STATE-AGENCY <br /> T. O . /s�)X- / `f O CORPORATION E-1 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME _ STATE ZIP S-, CODEIV.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 BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box binbicale 1 SELF-INSURED ED 2 GUARANTEE 0 31NSURANCE Q 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 6 EXEMPTION 0 W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSNAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS ACT# -OPTIONAL SUPVBOR-DISTRICTCODE -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) FOROa33Ad <br />