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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br /> CO LETE THIS FORM FOREACKXCILRYISITE <br /> MARK ONLY ❑ I NEW PERMIT RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PER ENTLY <br /> ONE ITEM ❑ 2 INTERIM PERMIT 6 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION 6 ADDRESS-(MUST BE COMPLETED)Y NAME <br /> ODA O �v <br /> /,^� NAME OF OPERATOR <br /> OR FACILITY <br /> _ <br /> ADD NE ST CROS TREET PARCEL 0(OPTIONAL) <br /> CI N STATE ZfC�`,ODF,�//1--'JA� SITE PHONE A WITH AREA CODE <br /> ---= � CA L✓Lv <br /> ✓ Box <br /> TOINDICATE ED CORPORATION 0 INDIVIDUAL ED PARTNERSHIP O LOCAL <br /> TCS NCY 0 COUNTY AGENCY Q L <br /> STATE-AGENCY 0 FEDERAL <br /> DISTRI <br /> TYPE OF BUSINESS ❑ I GAS STATION Q 2 DISTRIBUTOR RE/ IF INDIAANN I OF TANK T SITE E.P.A. 1.D.a(oplicnal) <br /> Q AT <br /> 3 FARM A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONEY WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PunuP.w ru AaPA rnnF <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAf-G27- <br /> 7� �/L//�.1y/y CARE OF ADDRESS INFORMATION <br /> MAS REE ORFSS ✓bobiMkaA � INDIVIDUAL l� LOCAL-AGENCY 0 STATE,AGENCY <br /> S/( 0 CORPORATION Q PARTNERSHIP Q COUNTY AGENCY 0 FEDERAL-AGENCY <br /> INN ME BTA 21P CODE H NE A VATJA AREACODE <br /> ZED- ero '2--A y� <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS• WX 10imnau I1 INOMDUAL O LOCAL-AGENCY 0 STATEAGENCY <br /> Q CORPORATION CD PARTNERSHIP O COUNTY AGENCY 0 FEDEIULAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [I—E= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ boa nvtlicau I I I SELF INSURED n 2 GUARANTEE l­_� 3 INSURANCE d SURETY BOND <br /> L_I 5 LETTER OF CREDIT L=I 6 EXEMPTION C1 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' checked. <br /> CI IECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOA LEGAL NOTIFICATIONS AND BILLING: <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 8 SIGNATURE) APPLICANTS TITLE DATE MONTHDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTIONR FACILITY aD02_410 ] <br /> 139n3 <br /> ! KE��� � 1 �. <br /> LOCATION COn� IOPrIONAL I ICENSUS TRACT TIOfjb1A f SUPVISO�2ISTRIT CODE -OPTIONAL <br /> U ZZ3 U I <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 /> Fonts A 112 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORIwva R6 <br />