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yui�p`c� <br /> STATE OF CALIFORNIA <br /> t s <br /> STATE WATER RESOURCES CONTROL BOARD ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA A <br /> COMPLETE THIS FORM FCR EACH F IS1TE <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION LD 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY -- <br /> Ot ITEM 2 INTERIM,PERMIT <br /> E RM IT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYlSITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> NAME OF ERATOR <br /> DdA OR FACILITY NAME Lv/ v� <br /> S Csj - <br /> I NEAREST CROSS STREET PARCEL 4(OPTIONAL) <br /> ADDRESS —6,/ 5,f <br /> 3 f; i ,� %� <br /> CITY' STATE <br /> ZIP C0 r� 51TE PWONE A WITHAREA Z��j <br /> CA � [.' z�5,7 8's <br /> TO INDICATE CORPORATION I/ BOXQ INDIVIDUAL Q PARTNERSHIP Q LOGAL•AGENGY Q COUNTY-AGENCY STATE-AGENCY Q FEDEPAL-AGENCY <br /> DISTTRICTS <br /> ✓ INDIAN n OF TANKS AT SITE <br /> TYPE OF BUSINESS 1 GAS STATION G 2 DISTRIBUTOR :j'FRVATION3 FARM Q 4 PROCESSOR Q 5 OTHER ST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> =NAME ,FIRST) PH E e WITH AREA CODE 568- DAYS: NAME(LAST,FIRST)S ,FIRST) <br /> PWONE b WITH AREA CODE NIGHTS: NAME{LAST,FIRST) <br /> H # H <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED CARP OF ADDRESS INFORMATION <br /> NAME <br /> ffl C"if /�'7 i r1 <br /> GENCY <br /> MAILING RST E 7 ADDRESS ./ hax Oo indicate [� INDIVIDUAL Q LOCALAGENCY QI STATE•A <br /> J <br /> Q CORPORATION [:] PARTNERSHIP QCOUNTY-AGENCY IQ FEDERAL-AGENCY <br /> PHONE n WITH AREA CODE <br /> CITY NAME rl G/ v STAj�j ZIP CC)C1 <br /> Ill. TANK OWNER INFORMA ION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OWNER <br /> ✓ boxtnlndicale Q INDIVIDUAL LOCAL-AGENCY QSTATE-AGENCY <br /> MAILING OR STREE ODRESS n _ <br /> ,{� � JV Q CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY Q FE4ERAL•AGENCY <br /> tCITYNAME CJ STATE ZIP CODE P ONE u WITH AREA CODE <br /> 1V. BOARD OF EQUALIZA ION 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 METHOD(S) USED <br /> box b indicate Q I SELF-INSURED Q 2 GUARANTEE Q 7 INSURANCE Q 4 SURETY SONO <br /> D 5 LETTER OF CREDIT D 6 EXEMPTION C7 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 BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND WILLING: I.= IL❑ III. <br /> kj <br /> THIS FORM HAS 8EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP'LICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 6 � 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT x -OPTIO�N'AL SUPVISOR-DTFII DE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF S INFORMATION ONLY.FCROCSJ -5 <br /> FORM A(5-91) (049 <br /> /wzz/ <br />