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STATE OF CALIFORNIA :� <br /> STATE WATER RESOURCES CONTROL BOARD ` <br /> >L UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A tl$,, <br /> I // COMPLETE THIS FORM FOR EACH FACILRY/SITE `'��rO�Y" <br /> MARK ONLY 71 t NEW PERMIT O 3 RENEWAL PERMIT 5CHANGE OF INFORMATION PERMANENTLY C <br /> ONE REM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM&� NAME OF OPERATOR <br /> ADDRESS Z NEARESTCROSSSTREET P i CEL#�(OPTIMAL) n <br /> CITY NAME STATE <br /> ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA S2A ^ ZCfi <br /> TOINDI RTE O CORPORATION NDNIWAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> I owner of UST Is a public agency,o nvWe the Iolowlng:name of Supervisor of division.section,or off ca which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS ATSITE E.P.A. I.D.#(opAXW) <br /> RESERVATION <br /> 5?'-3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME{ T.FIRST) PHONE#WITH AREA CODE <br /> IAk45C' E.U. O <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAM )TT,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAMECARE OF ADDRESS IIF RMATK)N <br /> te <br /> yt,' <br /> MAILING OR STREET ADDRESS ✓ boa blMkav, LVI`NDIVIDUAL (] LOCAL-AGENCY O STATE-AGENCY <br /> 2SZV . S CORPORATION O PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME ST/ATE ZIP CODE PHONE a WITH AREA CODE <br /> Vii- a�z0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) A/�✓r Y <br /> NAME OF OWNER /^. CARE OF ADDRESS INFORMATION <br /> !sKylixH S <br /> MAILING OR STREET ADDRESS ✓ boa to indices INDIVIDUAL (] LOCAL AGENCY =STATE-AGENCY <br /> Pon 1, O CORPORATION O PARTNERSHIP O COUNIYAGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EOUALIZATIPN UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4- -EI1_= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bIndicate I SELF INSURED 2 GUARANTEE 0 3 INSURANCE 1�4 SURETY BOND <br /> 51ETTEROFCREOIT 6EXEMPTION t�99OTHER -SQ`tC�f' 4 <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 ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L Ir 11.[IT/ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> V�. C.J�V�-�GZ' <br /> LOCAL AGENCY USE ONLYF <br /> COUNTY# JURISDICTION# FACILITY# <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) fo <br /> �7' — c; 110a33AA7 <br />