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'-� STATE OF CALIFORNIA �— <br /> STATE WATER RESOURCES CONTROL BOARD { •; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY F-1 I NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION E:j 7 PERMAN V E <br /> ONE ITEM 7_1 2 INTERIM PERMIT VI 4 AMENDED PERMIT [�] 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 2R 4�0 <br /> DBA OR FACILITY NAME `'�� J� NAME OF OPERATOR <br /> (p (,Ce- J <br /> ADDRESS NEAREST CROSS STREET PARCELr10PT10NAO <br /> CITU NAME ST ZIP AREA <br /> CA 9 3-76 SITE PHONEY V35-CA ,/S <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNE MP Q LOCAL-AGENCY Q COUNTY AGENCY Q STATE-AGENCY Q FEDERAL AGENCY <br /> DISTRICTS <br /> .TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR Q REIF INDIAN 11 OF TANKS AT SITE E.P.A. I.D.#Iapliana1) <br /> Q ATION <br /> 3 FARM Q 6 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE <br /> #WITH <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS bmblMica# Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDEMLIGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS W.mmkau Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL#GENCY <br /> CITY 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) HO i 4 4 - O 2 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bo1 b'utliGN Q 1 SELF-INSURED Q 2 GUARANTEE Q !'!N5UFxmcce Q L SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION 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.0 II.= III.a <br /> \J\.. 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&SIGNATURE) APPLICANTS TITLE DATE MONTWDAVNEAR <br /> LOCAL AGENCY USE ONLY GL <br /> COUNTY# -77214 Ly JURISDICTION# FACILITY# <br /> 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRA CTI-OPTIONAL SUPVISOR-DISTRICT CODE -OPTOWA1 <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LE{LST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESS THIS IS A CHANGE OF SITE INFQ�MATION ONLY. <br /> FORMA(5-91) I FOR0p77A5 <br />