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- 0un C C <br /> STATE OF CALIFORNIA '� <br /> STATE WATER RESOURCES CONTROL BOARD W 1a6a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �;p �..<: oe <br /> C LETE THIS FORM FOR EACUKCILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT RENEWAL PERMIT Lvr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE L <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) L CI <br /> DDA Ofl FACIL�IhT/Y NvAME �J ��a NAME OF OPERATOR <br /> AUDI <br /> NE STCRO TR� PANCELs(OPTIONAI) <br /> E [� <br /> Cl STATE Z COQF„/�D� SITE PHONEi WITH AREA CODE <br /> CA L'�` —TO I/ Box <br /> INDICATE 0 CORPORATIONINDIVIDUAL PARTNERSHIP DISTRICTS <br /> COUNTY-AGENCY Q STATE-AGENCY J FEDERAL AGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION E::] 2 DISTRIBUTOR E-] VA <br /> RESERDTION I OF TANK T SITE E.P.A. I.D.i(optional) <br /> 3 FARM ❑ A PROCESSOR [—] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> EiWITHABEACnnF <br /> NIGHTS: NAME(LAST,FIRSTI PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ��//�� CARE OF ADDRESS INFORMATION <br /> -���• ✓ boxbI we <br /> MAI G OR STREET ADDRESS O INDIVIDUAL O LOCAL AGENCY Cf STATEAGENCY <br /> lF1 CORPORATION PARTNERSHIP []COUNTY-AGENCY L__1 FEDERAL-AGENCY <br /> ITV N ME ST ZIP CODE'D— H NE M WR AREA CO 3 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS. VbolbiNkale C71 INDIVIDUAL =1 LOCAL-AGENCY 0STATEAGENCY <br /> Q CORPORATION Q PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE I WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ I4I4,-1_1� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ boa biiMkale I I I SELF INSURED (-)2 GUARANTEE t-] 3 INSURANCE I /SURETY BOND <br /> t-_1 5 LETTER OF CREDIT L]6 EXEMPTION F1 SS OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or If/checked. <br /> CHECK ONE DO%INDICATING WHICH ABOVE ADDRESSSHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: Lr_J 11; IU.I -J <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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY 1_7J0 r a <br /> COUNTY N i 04 JURISDICTION N FACILITY e4)()2 l(}9 <br /> 3 11� fir <br /> 39 �E�,� f - - - -- <br /> LLX]ATIONCOITk 1OPIIONAL (CENSUS TRACTX OPTIOfjMit SUPVISOfj�IS RI TCODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR ATION ONLY. <br /> MMM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORRAGETANK REGULATIONS <br /> -y) fORON7A R6 <br /> l �clD <br />