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c <br /> STATE OF CALIFORNIA r tel" <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> COMPLETE THIS FORM FOR EACH CILITYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT 15 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [i] 2 INTERIM PERMIT F-14 AMENDED PERMIT [7:16 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OR FACILITY NAME NAME OF <br /> DBA OPERATOR <br /> linl�r �4L �G�ln e � "erAG! '44Z:_ / NjF�,iyEST CRRO'SSS�SSTaEETET Qf� PARCEL#(OFnONAL) <br /> ADDRESS �— _ _ <br /> CITY NAME 'JtS�iS/CSU( STATE 21P CO SITE PHONE#WITH AREA CODE <br /> v2 CA <br /> TO INDICATE D CORPORATION a INDIVIDUAL Q PARTNERSHIP DISTRICTS COUNTYAGENCY I�STATE-AGENCY Q FEDERAL-AGENCY <br /> rTYPEOF BUSINESS 1 GAS STATION 2 DISTRION <br /> IBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opliooal) <br /> [] RESERVAT <br /> = 3 <br /> FARM 0 4 PROCESSOR O 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(LAST.FIRST) <br /> NIGHTS: NAME(LAST�G UCP,HONEHAREA COD��� NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> CAPE OF ADDRESS INFORMATION <br /> NAME <br /> �- ` <br /> MAlGid RRLDSS ST✓ bobinc <br /> q/ INDIVIDUAL <br /> OAL LOCAL-AGENCY STATE-AGENCY <br /> -AGENCY FEDERAL-AGENCY <br /> CORPORATION PARTNERSHIP L:71 COUNTY <br /> O4K TE ZIP CODE, ONE#WITH AI <br /> NAME <br /> 4 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> G�/E �GE�.e�� <br /> MAILING OR STREET ADDRESS ✓ box mlMical# INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP I=COUNTY-AGENCY D FEDERAL <br /> CITU NAME S�� 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 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box bindkale I= 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE (]d SURETY BOND <br /> 5 LETrEROFCREDIT Q 6 EXEMPTION 99 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 /> / <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.D II.� III. ]/I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT JY""�"' <br /> APPLICANTSNAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> q '1 o -2v-0 <br /> THIS ORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A7f 0 E INFORMATION ONLY.A 5 <br /> FORM A(5-91) <br />