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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD' _ UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ID <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED S <br /> ONE ITEM I 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ' <br /> ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB OR FACILITY NAME <br /> NAME OF OPERATOR <br /> ADORE_ <br /> 55 L4[-i/` ` NEAREST CROSS STREET PMCELN(OPIONAU <br /> CITY NAME `O S <br /> �` STATE 21P CODE SITE <br /> HONE,ywI�7/}y AREA CODE <br /> I/ BOX <br /> V-L cA 4S'Za E <br /> TO INDICATE CORPORATION E�] INDIVIDUAL PARTNERSHIP 0 LOCAL AGENCV 1-1 <br /> DISTRICTS COUNTY-AGENCY0STATE-AGENCY 0 FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D. <br /> RESERVATION IOR11OnBll <br /> 3 FARM 0 4 PROCESSOR OR TRUST LANDS QTY <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> �DAYS: NAME(LAST,FIRST) r P ONE M ITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NLAST,EePT ��2�P <br /> NIGHTS: NAME OIL, <br /> FIRSp P E A WIp ARE CODE, __ NIGHTS: NAME(LAST.FIRST) <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA E y RE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRE$ V <br /> �,Eo�x b-lMicale L-1 INDIVIDUAL I� -AGENCY SATE-AGENCY <br /> L 'OHPoRATION (] PARTNERSHIP Q COUNfV-AGENCY <br /> CITY NAME D FEDERAL-AGENCY <br /> STATE ZIP CODE P <br /> ONEAkVITH AREA CODE_ <br /> �6 v g SZ o ,/o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 193 <br /> NAME OF OWNER RE OF ADDRESS INFORMATION <br /> Cha _c LAC V� <br /> MAILING OR STREET ADDRESS ✓ box biMbad O INDIVIDUAL Ell LOCAL AGENCV <br /> (]STATE-AGENCY <br /> CITY NAME - O CORPORATION L__1 PARTNERSHIP (] COUNTY-AGENCY ED FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE x WITHAREACODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 1414-1- <br /> V. <br /> 4 4-1-V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box biMkala 1 SELF INSURED Q 2 GUMANTEE L_l 3 INSURANCE E-1 4 SURETY BOND <br /> I� 5 LETTEROFCREDT = 6 EXEMPTION BB OTHER <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 /> CHECK ONE BOX 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(PRINTED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/VEAR <br /> k .L <br /> LOCAL AGENCY USE ONLY <br /> 3OUNTY a JURISDICTION ILITY N l <br /> � — <br /> L( ;ATIONCDE -OPrIONAL CENSUS TRACTN � SUPVISOR-DISTRCTCODE -o Ov� ��/ <br /> J\"\I <br /> A5 aLa i3 <br /> \�` <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF ITE INFORMATION ONLY. fy <br /> ECRM A(12-BI) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOH00I5Ag6 <br /> N&V Sfg�/'�G�i`1'G — <br />