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STATE OF CALIFORNIA at �C <br /> STATE WATER RESOURCES CONTROL BOARD 3t} <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 4 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANEN Y OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION_ & ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPE,�°TOR <br /> Kc_) e_ a <br /> ADDRESS Q� NEAREP CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SiT PHONE#WITH AREA CODE <br /> Mal e C G) CA <br /> TO INDICATE PORATION INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR " IF <br /> IF INDIAN a OF TANKS AT SITE E.P.A. I.D.b(opf,mal) <br /> 3 FARM 4 PROCESSOR S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-oplional <br /> XYS: NAME(LAST,FIRST),-) PHLOh E X WITH AREA CCOE DAYS: NAME(LAST,FIRST) <br /> � - krl-- 29ii 2_3"t 31 b <br /> NIGHT8: NAME(LAST,FIRST) PHOKE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME — CARE OF DRESS INFORMATION <br /> Lc C Gt/ l� ti <br /> Cl <br /> MAILING OR STRE E_TADCRESS ✓ box Io indicate INDIVIDUAL E:f LOCAL-AGENCY STATE-AGENCY <br /> =;_WRPORATICN PARTNERSHIP Q COUNTY-AGENCY FEDERAL.AGENCY <br /> 1IIC,t,� HONE#WITH AREA CODECI AME STATEZip COC/ <br /> el L 7'0-? 6fQ5v` V/ kf) <br /> III, TANK OWNER INFORMATION- (MUST BE C6MPLETED) <br /> NAME OF OWNS CA OF ADPKESS INFORMATION f <br /> o v V q V I f <br /> MAKING DR STREET ADDRESS ✓ boxmunticale �1 INDIVID AL L_j LOCAL-AGENCY [] STATE-AGENCY <br /> f 6 �j�j Cc+lti1M1 �« CI CORPORATION 1- PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE#WITH AREA Cltg <br /> G+ ►1 ( 1 /CSS Cry f7/ Obi (a <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 METHODS) USED <br /> ✓ box w indicate 0 1 SELF-INSURED 2 GUARANTEE = 3 INSURANCE L]4 SURETY BOND <br /> 5 LETTEROFCRECIT B EXEMPTION 0 99 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 GOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑I 11.[7] Ill.❑ <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 /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> z mc) <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(5-41) FORQ073A-5 <br /> 14 <br />