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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 V 4 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORtl A <br /> �a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY E] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 17 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 50 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA AF CILITY NAME NAME OF OPERATOR <br /> MIA Z4cah r <br /> ADDR SNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ?) lera� <br /> CITY NAME STATE ZIP C �ZQ SITE PHONE#WITH AREA OgDE <br /> Ck�'6n Ca zbq <br /> ✓ BOX <br /> TOINDICATE CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 RESEIF INDIAN <br /> RVATION <br /> 5 OTHER #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DIyYS:�SfjRS T) D11 b � P H NE#WITH AREA DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FI T) PRONE## TH ARREEA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ahove_ <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> 0 INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF�(.W R CARE OF ADDRESS INFORMATION <br /> 1/G/ bo e- <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME [STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4-F4]- C) <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 GUARANTEE = 3 INSURANCE 0 4 SURETY BOND <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/x I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. I.[ III. <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 DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# LITY# <br /> (�eC, Ll <br /> LOCATION C PTIONAL CENSUSACT# -QPTIONAL SUPVIS R- IST�iICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A—CHANGt OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FOR0033A-5 <br /> � 0 • � <br /> s <br /> 9_'100< <br />