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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD •• eo <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT .J '3 RENEWAL PERMIT [--] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT L__j q AMENDED PERMIT El a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) 797 <br /> DBA OR FACILITYNAM NAME OF OPERATOR <br /> S '///i <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL#IOPfpNAL) <br /> CITU NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> c�fvN A CA V4 2- _ <br /> ✓ eox <br /> TOINDICATE CO RATION INDIVIWAL PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS 0 <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional <br /> 3 FARM 0 A DISTRIBUTOR <br /> OTHER O RESERVATION / <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE - DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(L,VST,FIgST) f/� PHONE#WITH REA CODE /A NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> S f /h A . c o . <br /> MAILING OR STREET A,DuHM ✓bo km 0 INDIVIDUAL LOCAL-AGENCY <br /> f, 0[ x.' 75-V/ CORPORATION O STATE-AGENCYCITY NAME D PARTNERSHIP � COUNTY-AGENCY Q FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> " f ! C4 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• ✓ box b OINDIVIDUAL <br /> �� O LOCALAGE [�STATE-AGENCY <br /> CITY—NAME D CORPORATION PARTNERSHIP COUNfYAGENCENCV F-1 FEDERAL#GENCV <br /> �� W +-. STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD=UNS1131LITY <br /> UNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HV. PETROT BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bo to mdIcale =1 I SELF INSURED 0 2 GUARANTEE 3 INSURANCE O d SURETY BOND <br /> O 5 LETTEROFCREOIT l=6 EXEMPTION C] W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boxI or II is ch ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I.D II III <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY <br /> KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTEDB SIGNATURE) APPLICANTS TITLE DATE MONTWDAV/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY.# JURISDICTION#—f— FACILITY# <br /> 3�%1 � � BKySa�s� <br /> LOCATION CODE -OPTIONAL ICENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OPTIONAL _ ' <br /> 3was 3 W 3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(i)OR MORE PERMIT APPLICATION'• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 <br /> 0 FOR0033A R6 <br />