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STATE OF CALIFORNIA ^ee o^ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> t r, <br /> a. .. <br /> COMPLETE THIS FORM FOR EAC ACILRYISITE <br /> MARKONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY"QSM SEE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OF OPERATOR <br /> G / T>a A D <br /> ADDRE NEAREST CROSS TREET PARCEL#(OPTIONAL) <br /> CI NAME STATE ZIP CODE *WIP.4 AREA CODE <br /> CA <br /> TOINDIICCATE O CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY D FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR RESV IF INDIAN ERVATION #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAV : NAME IL T, IRST) PHONE#WITHgpEA 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 /> NAydG -/ -,-_Y 74 F._- �� CARE OF ADDRESS INFORMATION <br /> MAPLI DRESS ✓ bo.0 Aukate = INDIVIDUAL <br /> � LOCAL-AGENCY �STATE-AGENCY <br /> . d• Q 0 CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY 0 FEDERALAGENCY <br /> CIN NAME ST ZIP E HONE WIT REA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEQFOWyER �^ CARE OF ADDRESS INFORMATION <br /> //YAIs/LnJ J <br /> MA�IL�pPOR STREET ADDRESS _ ✓ box bindkale 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> / - � a(()JL, 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME /D / STATE ZIP CODE HONE#,WITyI pREACODE .� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise.) Y/�lr !/Ln�! <br /> TY(TK) HO F4174 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bindkate D I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE D A SURETY BOND <br /> D 5 LETTEROFCREDR D 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or ll' checked. <br /> CHECK ONE BO%INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11 III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION It _ FACILITY# <br /> 5:K <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 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 SR OG ATION ONLY. <br /> FORM A(5-91) FOt10 AS <br />