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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD �so�w, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SI7E y a® <br /> MARK ONLY ❑ 1 NEW PERMIT , m <br /> ONE ITEM ❑ 3 RENEWAL PERMIT <br /> ❑ 2 INTERIM PERMIT 5 CHANGE OF INFORMATION -o-Y <br /> ❑ 4 AMENDED PERMITT PERMANTLY <br /> I. j 0C <br /> FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLE7s TEMPORARY SITE CLOSURE ElEN <br /> _ <br /> DBA OR FACILITY ryJAME I <br /> LI%I ) <br /> If' I"(,L t/I�� ( � Yu(JY NAME OF OPERATOR <br /> ADDRESS rr I <br /> ( }-C v� N RE TCROSS STRE <br /> CITY NAME / o„Y, PARCEL tl(OPTIONAL) <br /> ODEz SITE PHONE x WITH AREA CODE <br /> ✓BOX D CORPORATION CA 1 J d <br /> TO INDICATE INDIVIDUAL (] PARTNERSHIP <br /> •tloxnerd USTea ubG:a ED LOCAL-AGENCY <br /> Y ED COUNTY-AGENCY' r <br /> p 9erxy,amplete the lolbwi7g.aamedsupenisordtlHiapn, OPOW DISTRICTS 0 STATEAGENCY' r�FEDEgAI.-AGENCY' <br /> TYPE OF BUSINESS fn sedlNl oraMka wtlyl e�ales Me UST <br /> 1C� 1 GAS STATION O 2 DISTRIBUTOR <br /> 3 FARM VIFINDIAN x OF TANKS AT SITE E.P.A. I.D.❑ A PROCESSOR ❑ 5 OTHER RESERVATION #(optional) <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> OQyS: NAME(LAST,;FIRST)` PHONE x WITH AREA CODE EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> : / m e DAVS <br /> U1 VI q^ PHONE#WITH AREA CODE: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,F ST) !N �S� (7 <br /> PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE x WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME <br /> vCARE OF ADDRESS INFORMATION t vj t' <br /> MAILING OR STREE7 ADDRESS <br /> '7vx ✓ boxlo kJ*me <br /> CITY NAKIE f�CORPORATION (] INOMDPARTNEAL O LocAL-AGENCY Q STATE-AGENCY <br /> COUNTY-AGENCY ED FEDERAL-AGENCy <br /> ST TEA ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l S Oc ' S S 3 v <br /> N E FOWNER <br /> A4t( IA A r , CARE OF ADDRESS INFORMATION <br /> MAILING,AIOR STREET ADDR(E�SS <br /> 7 U`I Z TU HA v e Y r I ✓ boxto#rtluale ID INDMDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CITY NAME ED CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCV QFEDERAL-AGENCY <br /> '.) r /, STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUAvLIZATION�UST STORTAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> 1r(TK) HO 4 <br /> _n_ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxlo vd.e 01S -NSURED ( I� 2 GUARANTEE I�3 INSURANCE (]1 SDRETY BONA <br /> O aSTATE Fl1NDdCHIEF FINANCIAL OFFICER LETTER O95TATE R)NDBCERTIFICATE OF DEPOOSR 0110 LOCALGOVTVTOMECHANISMOOOOTHER <br /> ��ND ' <br /> A. 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.❑ II.0 ql,❑ <br /> THIS FORM HAS BEEN_COMP ETED UNDER PENAL TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> =77 <br /> MMERINTED S SIGNA <br /> I TANK OWNER'S TI E DATE ONTWDAV/YEAR <br /> I _ EL t� ;;:r P� IZ 7rf A <br /> LOCAL AGENCY USE ON <br /> COUNTY# JURISDICTION# -T— <br /> mI�TI FACILITY# <br /> IOCAT10N CODE -OPTIONAL CENSUS CTx - TIONAL L <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> A(6-95) OWNER MUST FILE THIS FORM 4 AT JHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUe""TORAGE TANK REGULATIONS <br /> 'GR01 <br />