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Cr. <br /> ST ATE OF CALIFORNIA <br /> IOISTATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o� <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY IF7 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C SED <br /> ONE ITEM El 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE qq <br /> 1. FACILITY/SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILf7Y Mp�E+ NAME OF OPERATOR <br /> ADDRESS4J f/Vr l y� NEARES7CROSSSTREE7 I PARCEL 9(CPTIONAQ <br /> UY r'� l{�'+'t1 S I <br /> CITY NAME STATE ZIP CODE SITE PHONE o WITH AREA CODE <br /> CA q - GCas <br /> ✓ BOX <br /> TOINDICATE CORPORATION INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY C FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF 3LISINESS �1 1 GAS STATION I� 2 OISTRi$UTOR RESERVATION IF INDIAN x OF TANK A7 SITE c.P.A. I-D.x!ppripalJ <br /> 3 FARM 4 PROCESSOR I= 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME_(L,AS�,rIRST}, P`,ONE x WITH AREA COCE DAYS: NAME(LAST•;1 S/]T)G/�,-.�/J <br /> NIGHTS: NAME(LAST,FIRSTS PHONE x WITH AREA CODE NIGHTS:. NAME(LAST,FIRST) <br /> PFJ F O'NITH A PC 1•= <br /> 11. PROPERTY OWNER INFORMATION MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFO RMATkCN <br /> I <br /> MAIL,NG OR STREET ADDRESS ✓ WR 4'naiws I� INDIVIDUAL �,' LOCAL AGENCY ',_, STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL AGENCY <br /> CITY;NAME STATE ZIP COCE PHONE x WITH AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Qa1lDmKatY Q INDIVIDUAL LOCAL,AGENCY Cj STATE-AGENCY <br /> ©CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE x 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 /> ✓ bax bwQitam Q 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q 4 7RETY BOAt0 <br /> (] 5 LETTER OF CREDIT Q d EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notitication 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: L= IL= 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(PAIN TED&SIGNATURE) APPLICANT'S TITLE DATE MON TWOAY EAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION 0 FACILFFY# <br /> V/v37 <br /> LOCATION CODE •OPTIONAL CENSUS TRACT A •OPPONAL SUPVISOR-DI RICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FOAM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FCRM A(5-91) FCRO MM-S <br /> - <br />