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STATE Of CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> y <br /> COMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY qz/' NEW PERMIT a 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT SED SITE <br /> ONE ITEM Ej 2 INTERIM PERMIT Q d AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITYNAME NAME OF OPERATOR <br /> ADDRESS / NEAREST CROSS STREET I PARCELi(OPTIDNAU <br /> CITU NAME STACA ZIP CODE SITE PHONE a WITH AREA33 <br /> ✓ BOX YC9 <br /> TO INDICATE O CORPORATION Q INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY AGENCY Q STATE.AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSJ t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN i OF TANKS AT SITE E.P.A. I.D.i(wtiwap <br /> RESERVATION <br /> O 3 FARM O A PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAM LAST,FIRST) PHONE a WITH AR OOE DAY ' NAME(LAST,FIRST) �,�,A <br /> �t — 25e^ 1 &12 <br /> NIGHTS: NAME(LAST,FIRS PHONE i WITH AREA CODE NIGHTS: NAME(LAST. RST) <br /> 211H AREA COOP <br /> ll. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> 'hoK.S" CARE OF ADDRESS INFORMATION <br /> 'z,u� r`a G c, <br /> LN/G OR STREET ADDRESS %/%/ WX0 Wane INDIVIDUAL 0 LOCAL AGENCY Q STATE AGENCY <br /> 2 D DCORPORA71ON PARTNERSHIP OCOUNrYAGEHCY FEDERAL-AGENCY <br /> CITY NAME ISTA ZIP CODE /' PHONE i WITH AREA COO <br /> G 7r�!^ Af-- Zp/yr <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER T CARE OF ADORESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Lw oiMkaN 0 INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> (]CORPORATION Q PARTNERSHIP Q CDUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i 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 -LU �Ll Q 17I 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ fmmWkaM I SELF-INSURED Q 2 GUARANTEE (] a INSURANCE <br /> O 5 ET ER OF CREdT 0 2 EXEMPTION W OTHER O a SUR! <br /> YBOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless bo I or II is 04. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE A T <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY /✓' <br /> COma 741 OS 2� JURISDICTION a FACILITY a <br /> LOCATION COD TAONAL CE/N/SUUS/T`RACJ��.OPT ML SUPVISOR-DISTRICT CODE -OPTpNgL <br /> /./�/ O <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> FOgON3A5 <br />