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,URCes <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM Ao <br /> fUNN� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 N PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 ERMANENTLY CLOSED ITE <br /> ONE ITEM INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILI�AIdE NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Q kv, VY <br /> CITY NAME STATE ZIP CODE SITE PHONE fWITH AREA CO <br /> CA C,(J RDE <br /> 6 _X39 <br /> TOINDIC TE CO RATION INDIVIDUAL = PARTNERSHIP (]LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D YS: NAME BLAST,FIRST) PHONE#WITH AREA CODE DAY NAME(LAST FIRST) <br /> 7j-.-/7/9&- - T S • <br /> NI TS: NAME(LAST,FAST) PHONE#WITH AREA CODE HTS: NAME(LA ,FIRST) A CODE <br /> (NAME <br /> PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> a OF ADDRESS INFORMA 9je6 V_10 We,6A <br /> G OR STREET AD RESS ✓bo ndicate 0 INDIVIDUAL LOCAL-AGENCY � STATE-AGENCYd � CORPORATION Q PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGEN Y <br /> N �r nn 11 STATE ZIP CODE PH NE#WITH A A CODE <br /> Y ILS l D �� �502 t <br /> t�I . TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION / <br /> S <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL _ _LOCAL-AGENCY (] STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME [STATE ZIP CODE ____[PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to Indicate F-1 1 SELF-INSURED 0 2 GUARANTEE ] 3 INSURANCE Q 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 6 EXEMPTION ] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless boxi or II is cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. <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&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNE R <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION COD OPTIONAL CENSUS TRACT# -OPTIONAL a SUPVISOR-DISTRI T CODE -OPTIONAL <br /> OQ/Z) /h <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) �� / / /FOR0033A-5 <br />