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'45CUa�f9 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> 1 <br /> COMPLETE THIS FORM FOR EACH FACILrrYISITE <br /> MARK ONLY F__j 1 NEW PERMIT O 3 RENEWAL PERMIT5 CHANGE 61'i'1NFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E 2 INTERIM PERMIT 0 4 AMENDED PERMIT 9,6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> ac-c� ar7�'G i-.rc y-a z74 <br /> ADORES NEAREST CROSS STREET PARCEL M(OPTIONAL) <br /> YO GJ Gtr a r T,i �44 &/'-4./C_C3/,v <br /> CITY NAME STATE ZIP CODE S TE PHONE x WITH AREA CODE <br /> CA 9"r2_p G o g YBOX <br /> � <br /> TOINDICATE tAl CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ® 1 GAS STATION a 2 DISTRIBUTORQ ✓ IF INDIAN x OF TANKS AT SITE E.P.A. L D.0(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> f,'✓� DAY NAME(LAST,FIRST) HONE x WITH AREA CODE DAYS: NAME(LAST,FIRS �J�f �— YJ <br /> LC. <br /> 2�.�z T�a� 9 zzs�i y L�tiG I <br /> NIGHTS: NAME ITAST.FIRSTf PHONE N WITH AREA CODE NIGHTS: NAM T,FIRST) <br /> g Z4.3-.308f <br /> c.� II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> 1(J1� NAMEN <br /> INFORM <br /> CARE OFAODREsATI TEXACO REFINING AND t;Nc. ,� <br /> N: Kel./�r�a �e - /C) <br /> MAILING OR STREET ADDRESS ✓box bIndicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> V, f1_<mRPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE<WITH AREA CODE <br /> tilverlo� / C.T L' eg <br /> 2-0c)0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �I TEXACO REFINING AND MA'.:KETiNG iNC. /�1Ti✓.' ��f-r Cc�c�, i.�a..�►� <br /> MAILING OR STREET ADDRESS ✓box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> V1 ul <br /> -?CC2DircloRPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE o WITH AREA CODE <br /> a ! G'4 �,por 2"- 5/72-6 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - d d / -2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> S LETTEROFCREDIT Q 6 EXEMPTION Q 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: 1.0 II.O 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 MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 1t JURISDICTION 9 FACILITY# d- <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 ONL . <br /> FORM A(5-91) FOR0033A-5 <br />