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3c <br /> STATE OF CALIFORNIA • 'tso°a ee <br /> STATE WATER RESOURCES CONTROL BOARD `P o°"a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ve <br /> s , d <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> AONE�I�TEM <br /> NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SjTE� <br /> 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> CDIBTY NAME Fj: � NNAME O O RATO <br /> ggqggg <br /> - <br /> PCROSSTFEE AflCELp(0PIONAL)65� /„7� `/ l <br /> STA E ZIPCGQ <br /> SITE PHONE#WITH AREA CODE <br /> CIE �1 <br /> ✓ BOX CA 3 <br /> TOINDICATE OC PoRATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY I� COUNTY AGENCY STATE-AGENCY O FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS I GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OFT AT SITE E.P.A. I.D.tt(optimal/ <br /> 3 FARM � 4 PROCESSOR 5 OTHER O TRUSTRESERATIONNDS S /CfV <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D/tt/ryyyLV�S1J,'' NNp/M (LAST,FI STT) i/ / - PHONE#WITH REA COD DA S: (LAST,FIRST) <br /> NIG Ts: AVEtl (( iT)K / PHONE#WITH E ODE NIGHNAME(LAST,FIRST) <br /> wild '2iq4�j J <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED! <br /> NA EL)n 4 I ) / CARE OF ADDRESS INFORMATION <br /> MAI ()p$'RS ADDR/� / ✓ box bl�kak INDIVIDUAL O LOCAL-AGENCY <br /> _ U (ti�J( I�STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP 0 COUNTYAGENCY I� FEDERAL-AGENCY <br /> CITV NApA� /) - SyyTE ZI E d5 aD PHO ITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET-ADDRESS ✓ box biMicala L-1 INDIVIDUAL <br /> O LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUMY-AGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE#WITH ARE-CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ �4 f 4 -[Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Wx 0indicate I SELF-INSURED0 UARANTEE 31NSURANCE d SURETYGOND <br /> U 5 LETTEfl OF CREDIT 6 EXEMPTION 1-f 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles ox I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.Y II.D III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/VEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 39 T.Ll ,�3�13 <br /> LOCATION f.OD� -OP iIGNAL iCENSUS TRACT IpA(AL SUPVIS R�I$TR TCO -QPrAAL <br /> U U Gl/ O ✓2/ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORMA3,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(1291) FILE THIS FORM WITHTHET RE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGEATIONS <br /> 0 <br /> FOR0033A86 <br />