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• STATE OF CALIFORNIA • •e°o°" e. <br /> STATE WATER RESOURCES CONTROL BOARD oib <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY ❑ ( NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> l� l <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ae4P <br /> DBA OR FACILITY NAM /� / _ NAMEOFOPERATOR <br /> III GL(LL 5-/�tLo /Ai vi 0 V G.T[OYUS <br /> ADDRESS NEAREST CROSS STREET P..CELN(OPTIONAU <br /> R3 � s <br /> -CITY-NAME _ / / - <br /> S LfG T L�n STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> ✓ Box CA <br /> TO INDICATE O CORPORATION 0 INDIVIDUAL ] PARTNERSHIP I] LOCAL-AGENCY COUNTY-AGENCY EI STATE-AGENCY <br /> DISTRICTS � FEDERAL AGENCY <br /> TYPE OF BUSINESS ❑ 3 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(oplip�aQ <br /> 3 FARM O4 PROCESSOR 5 OTHER ❑OR RESERVTRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> 9 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH REA CODE NIGHTS: NAME(LAST,FIRST) ODF <br /> sCt"e— <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> CARE OF ADDRESS INFOgMATION <br /> MAILING OR STREET ADDRESS ✓ box blMicate <br /> U <br /> r' 17:1INDIVIDUAL LOCAL AGENCY ] STATE AGENCY <br /> CITY NAME ig z!j Q CORPORATION II PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> STq,TE ZIP CODE <br /> { � �� l/JTx PHONE#WITH AREA CODE <br /> 9ot�os /y- 975-- yj <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFOflMATION <br /> .n P S 7Z- <br /> MAILING OR STREET ADDRESS- ✓ box b iMlcale <br /> O INDIVIDUAL ] LOCAL.AGENCY ] STATE-AGENCY <br /> CITY NAME Sre rti2 �` CORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY ] FEDERAL AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> Sr2 ixL a r .7r: <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4 L�- Q Z 2 (� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bintlicale F-�] t SELF INSURED ]2 GUARANTEE [-:13 INSURANCE <br /> U 5 LETTEROFCREDIT O [-199 OTHER <br /> 6 EXEMPTION ]1 SURETY BONG <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or Ills c ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> I. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE REST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PgINTED 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTH/DAV/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 y RACT - Z_ C a rNj Sy3 <br /> LOCATION CODE ,OPTIONAL ICENSUS TRACT SUPVISOR-DISTRICT CGDE -OPTIONAL <br /> D / 3a-3 3&Y/v3 --- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WRH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 0 FOR0033A.RS <br />