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• psoo. <. cc <br /> STATE Of CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACbPKACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ S RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 T Y OSEO SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 5 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> GSA OR FACILITY NAME I NAME OF OPERATOR <br /> ADDRESS /-�w/.�- NEA ST CROSS STREET PARCEL$(OFrIONAW <br /> CITY NAME STATE ZIP CODCA 1EI <br /> / � SITE PHONE z WITH AREA' 1�. <br /> 7N(—i J <br /> TOINDICATE CORPORATION Iv Box NDIVIDUAL PARTNERSHIP I�LOCAL-AGENCY Q COuNrY-AGENCY O STATE-AGENCY I= FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ p V IF INDON IO IAN A OF TANKS AT SITE E.P.A. L D.0(optimal( <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE 9 WITH AREA nnng <br /> NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS:NAME(LAST,FIRST) <br /> PWONE a WITH AREA <br /> II. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa 13 mx=0 Q INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY 0 FEOERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa INinokau Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP CJ COUNIVAGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. <br /> TY(TK) HQ F4_74 - <br /> Q t! <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa oiMicso Q 1 SELF-INSURED Q 2 ARANTEE 0 3 INSURANCE O a SURETf CONO <br /> O 5 1ETTEROFCREDIT EXEMP ION 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 /> CHECK ONE BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ It.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY n <br /> 511 cu 144-S# = 101Q I f 17 F-777 <br /> LOCATION CODE -OPTIOCENSUS TRACT SUPVISOR-OITRICT CODE -OPTIONAL( <br /> i <br /> NA ( LfY� Mr-� <br /> V <br /> THIS FORM MUST BE CCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SfTE INFORMATION ONLY, <br /> FORM A(5.91) PoROGMA-5 <br />