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• 'GSOJR<(y <br /> STATE OF CALIFORNIA c"; <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A gb o <br /> COMPLETE THIS FORM FOR EA ITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PE ANENTLV CLOSED SRE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME // NAME OF OPERATOR <br /> r Ice 5' /-/v li a- PARCEL#(OPTIONAL) <br /> ADDRESS ��-- NEAREST CROSS STREET <br /> J4 U��S <br /> CITV NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA o <br /> TOIN BOX O CORPORATION l� INDIVNUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY l�STAT&AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RE,/ IF INDIAN <br /> SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) a,rF PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> a,-eL /�c6%o - Y66 -3 Sum <br /> PHONE X WITH AREA rnnP <br /> NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> S'h NtiR S 4 twQPRONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> rV vl-c-L t rrf! S '� <br /> MAILING OR STREET/A!DDRESS !! ✓ box bindMo IVIOUAL Q LOCAL-AGENCY IEj STATE-AGENCY <br /> IL0 CORPORATION 1� PARTNERSHIP 0 COUNTY AGENCY Q FEDERAUAGENCV <br /> CITY NAME STATE ZIP COD; 9 PHONE#WITH AREA CODE <br /> 04— <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMicate Q INDIVIDUAL 0 LOCAL-AGENCY [� STATE-AGENCY <br /> COflPoRATION ] PARTNERSHIP COUNTY-AGENCY O FEDERALAGENCY <br /> CITU 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 �zi]f41-I ala to <br /> V. PETROLEUM UST FINANCIAL PONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ box bintlkate 1 SELFINSURED L-12 GUARANTEE 03 INSURANCE O4 SURETY BOND <br /> 5 LETTEROFCREDIT 0 6 EXEMPTION Cf 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box Is Checked. <br /> CHECK ONE 80X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ 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(PRINTEDB SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# M/K.ES 4/3 <br /> LOCATION CODE -OPTIONAL iCENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 3n I 3z3 (�'D <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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A R6 <br /> 0 0 1 \ <br />