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k <br /> STATE OF CALIFORNIA <br /> e i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �e <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CL O SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 7A OR FACILITY NAME NAME OF PERATOR <br /> i<c0 oac-rs �oMr'AN� S�ct.k-_ -, aH,wa� �R.;=.10 <br /> ADDRESS NEAREST CROSS STREET PARCELN(OPTIONAU <br /> 2-T00 IIUE'�,T WA" 1a147C J <br /> CITY NAME STATEZIP CODE SITE PHONE x WITH AREA CODE <br /> i. c �152ea3 ca1 95 2Q3 209 4(c(a - rfqG� <br /> TOO INDIPoC TE LV4 CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY C] COUNTY AGENCY [-I STATE-AGENCY FEDERAL AGENCY <br /> DSTRiCTS <br /> TYPE OF BUSINESS 1 GAS STATION [::] 2 DISTRIBUTOR = ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 3 FARM � 4 PROCESSOR I� 5 OTHER OR TRUST LANDS 1 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIR3n <br /> &C �� do r II ' ���'`�> L(&6- La tidy , <br /> n I�u (pcu ) L9401 <br /> NIGHTS: NAME(LAST,FIRST) -PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ;-e-te . , Ch(I: l ,_ 12051 3( Ion. -l0 �G��Lv� Pn l2ouPHQN) 3(�9 lyloyo <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA E CARE OF ADDRESS INFORMATION <br /> 12l arLr,>L a CoM�A vy Nar) S encu <br /> N,iAYIJjgGOR STREET ADDRESS ✓45oa bilbkale E-7 INDIVIDUAL 0 LOCAL-AGENCY CI STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP 0 COUNTY AGENCY = FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Lo Ati(,CLsS C'A °ISI - 05av 21))) 413(0 - 04,s-2-- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED), <br /> NAMEOFOWNER CARE OF AgDRESS INFORMATION <br /> AFL( O mat%"i5 CMMi�A� brOG S enter <br /> MAILING OR STREET ADDRESS ✓ WX MInd'ealo D INDIVIDUAL (] LOCAL AGENCY L7 STATE AGENCY <br /> � <br /> �J CORPORATION Q PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> _ XNCIE C S CA 80051 - G5 213) GF f, -06 52-- <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO L4r4O 5 0 (r <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Mc to Indicate (`� 1 SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE L 4 SURETY BOND <br /> I� 5 LETTER OF CREDIT 0 6 EXEMPTION C] W 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.m I.u III. <br /> 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 MONTHIDAYNEAR <br /> IA ( L 1 z I I F <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> � <br /> - L�� <br /> # <br /> LOCATION CODE OPTIONAL '.CENSUS TRACTOPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL V <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 /> FORMA(1z911 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> fOR0033AR6 ' <br />