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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A W <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Aacp �Ac��\ � Sgla°I U�►CHT ENTeQ ,seg <br /> ADDRESS NEAR%CROSS STREET PAACEL0(OPTIONAL) <br /> �3 SO • \\SUfV l�A W VOtNN(OTO N <br /> CITY NAME STATE ZIP CODE SITE PHO E#W1 AREA CODE <br /> CA "iS'Los (tog y • to o13 <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY `l FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS V 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.0(optimal) <br /> f� 3 FARM f� 4 PROCESSOR = 5 OTHER OR RESERVATION 3 <br /> TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WI H AREA CODE DAYS; NA.M€(LAST,FIRST) <br /> �\GNT �o\��NS C �l�-1ob33 w�raaTwRe�ce. <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIR T) CQaa 212_(03� 9 <br /> MANPs(e.Q ont %&(1 - 33 Are-0 y\ChN14fer r CQ P ITH AREA CODE <br /> `u <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> eco 6�ue'>K E)Av S <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY <br /> STATE-AGENCY?.0 ' <br /> S .O - bcq, ��� CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a TH AREA CODE <br /> �RTes % <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNE�R,, CARE OF ADDRESS INFORMATION <br /> QI'oc�uck� Cp . E1} S <br /> MAILING OR ST ET ADDRESS ✓ box toind"te = INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY <br /> -O - bc, ��� ORPORATION = PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONEITH AREA CODE <br /> 4 Gs%C< �0�o2-)003$ (-I1� e-70-t4A <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ K4]- O C3 1 d ICr <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate t SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LEITEROFCREDIT 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.a 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 8 SIGNATURE) APPLICANTS TITLE DATE M NTW XON,gyc\ �Nv.Co 1,ax,c� l�arnw , $ zo O b <br /> LOCAL AGENCY USE ONL <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -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 SITE INFORMATION ONLY. <br /> FORM A(5-91) f. `` `` ` <br /> -Tn.. SO.ty �00'g1,\N C0 • 1'b�1\� t'�eN�N\ EN P. ISeIM FOR0033A-5 <br /> ��Y <br /> 1'•0 . box 'LOA <br /> �1t'vc�i,-Co a, Cp► . (tS-L41 <br />