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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> QvonN N <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> ONE REM 2 INTERIM PERMIT Ej 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ©/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR F/AA�CILITY NAME /- NAMEOFOPERATOR <br /> rGd <br /> ADDRESS - NEAREST ROSS STREET PARCEL#(OPTIONAL) <br /> 10 m] Mi <br /> CITY NAME STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> vv\ ti C CA 5 3 3 <br /> T NDIOX <br /> ATE O CORPORATION D INDIVIDUAL []-PARTNERSHIP D LOCAL-AGENCY Q COUNTY-AGENGY E-1 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESSEn- I GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN l#OF TANKS AT SITE E.P.A. I.D.#Io tmnal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) -PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME 'P1,;1 CARE OF ADORESS INFORMATION <br /> �\f.Qtr <br /> MAILING OR STREET ADDRESS ✓ hoxblMkaU = INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY <br /> _ 1.1!2.C2 Yb S ewl CORPORATION = PARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> mC' -, E-tcs (, 9533,( <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNERT� CARE OF ADDRESS INFORMATION <br /> vhr1 F trXtr <br /> MAILING OR STREET ADDRESS•v ✓ box bindicate = INDIVIDUAL 0 LOCAL-AGENCY I�STATE-AGENCY <br /> ti L Lo o S-C M.L =CORPORATION 0 PARTNERSHIP 0 COUNTY AGENCY FEDERALAGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> Al-? <', z953 3 6 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate I SELF INSURED =1 2 GUARANTEE = 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT =6 EXEMPTION Rrg 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.L��r it.E—] III,E <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 MONTH/DAYNEAR 1 <br /> LOCAL AGENCY USE ONLY <br /> COU.NTYIt _. JURISDICTION <br /> It FA�CILITI YI# <br /> 47/w 77- <br /> r <br /> 1 - <br /> _iI']_j <br /> LOCATION CODE OPTIONAL ES <br /> -OPTIONALSUPVISOR-DISTRICT CODE -OPTIONAL <br /> Lv z 6 3 II-ri3 <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(12 el) FILE THIS FORM WITH T OCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033AAS <br />