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N(�• a <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> MARK ONLY �O 1 NEW PERMIT 3 RENEWAL PERMIT r f 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 u <br /> 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRAOR FACILITYN-A'ME lnola NAMEAF OPERATpR o <br /> A15DRESS6 <br /> - v / NEARES�Tr ASSSTRFET PMCELMtOPfpNAy <br /> CITY ST CA ZIP CODE $KE` NEN WI�i gBEA COpE/ <br /> Box <br /> TO INDICATE CORPORATION (] INDIVIDUAL 0 PARTNERSHIP 0 LOCAL AGENCY 0 COUNTYAGENCY O STATE-AGENCY '7JD�FEDERAAL'#6GECNOY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR 0 ✓ IF INDIAN a OF TANI($AT SITE I E.P.A. I.D.A'tapliowl) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> OR TRUST LADS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PH E AW T AREA CgPE DAYS: NAME(LAST,FIRST) <br /> z-a-179Z., PHONE A WITH AREA CO <br /> IGHTS: NAME(LAST,FIRST) PHONE♦WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CO <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /_oo I A _ <br /> MAILING OR STREET DRESS n ✓ box b inEieala 0 INDIVIDUAL LOCAL-AGENCY STAT6AGENCY <br /> /D ///i+CG�j �I G� OCORPORATION OPARTNERSHIP 000UNTY AGENCY FEDERAL-AGENCY <br /> CITY,NAME - STAT ZIP CODE PHONE a WITH AREA CODE <br /> b <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWbLER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa 0Imwale O INDIVIDUAL LOCAL AGENCY [� STATE AGENCY <br /> a V_'9!57 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ME J STATE ZIP CODE PHONE t WITH AREA CODE <br /> /`/V�C�/• T� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 0 questions arise. <br /> TY(TK) HQ [4141- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box birdkab [_� I SELF-INSURED [J 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 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.O it.X <br /> 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AN CORRECT <br /> APPLICANT'S NAME(PR INTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION <br /> LOCATION CODE OPTIONAL CENSUS TRI -OPTIONAL SUPVI50li-DISTRICT CGDE -OPTIONAL r T. <br /> 3 CJ�i.i) C. <br /> THIS F RM 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(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REM ILATIONS <br /> FOR0033A R6 <br />