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1 <br /> STATE OF CALIFORNIA •, sow•«.. <br /> STATE WATER RESOURCES CONTROL BOARD p, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A yc� , <br /> y� <br /> COMPLETE THIS FORM FOR EAC ACILITYISITE <br /> MARK ONLY Q I NEW PERMIT O D RENEWAL PERMITS CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q d AMENDED PERMIT E] S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> DBA OR ILITY NAME /�a� NAME Of OPEgA;Oqn n <br /> ADDRESS, �l' ^ � NEA ST CROSS ST PARCELA (OPTIONAU <br /> CITY NAME V STATE (LC ZIP OD I PHON # WITH AREA CODE <br /> AZD �i y -sso y <br /> ✓ BOX <br /> TO INDICATE - 0 PORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS FV 1 GAS STATION Q 2 DISTRIBUTOR RESERVA✓ IF INDIAN a OF TANKS AT SITE E. P. A. L D. # (optimal) <br /> TION 3 <br /> Q ] FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br /> DAYS' 'A, ME (LAST,j�RST) pHONE # WITiAREA COOS . DAYS: AM (LAST, FI ST) <br /> � - 7 <br /> NIGHTS: NAME (LAST. FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST. FIRST) GQ L /'VV <br /> R <br /> II. PROPERTY OWNER INFORMATION • MUST BE COMPLETED <br /> NAMECARE ADD INFOR ESS TION <br /> ink C ( p Vee earn b onto <br /> MAILING 08 STREE ADDRESS ` %e' box bindi to L.] INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITU NpME� STATE,`/f <br /> ZIP CO21 64 ?HONEWITgE 8f �t✓ <br /> III. TANK OWNER INFORMATION (MUST BE COMPLETED) AE <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 9(40 <br /> L44 <br /> MAILING OR STREETADORESS ✓ boa birbbate INDIVIDUAL E3 LOCAL-AGENCY O STATE-AGENCY <br /> = CORPORATION O PARTNERSHIP Q COUNTY.AGEACY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION jUST STORAGE FEE ACCOUNT NUMBER • Call (916) 323-9555 if questions arise. <br /> TY (TK) HQ 4 4 - I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY • (MUST BE COMPLETED) — IDENTIFY THE METHOO(S) USED <br /> ✓ Dao oIndicate M I SELF-INSURED 0� � GUARANTEE O 5 INSURANCE EDA SURETY80NO <br /> O 5 LETTEROFCREDIT I$ a 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 isochecked, <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I' D II.y <br /> TIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT <br /> APPLICANT'S NAME (PRINTED & SIGNATURE) APPLICANTS TITLE DATE MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY # JURISDICTION # FACILITY # - <br /> ® El <br /> LOCATION CO� iOPT)ONAL ( CENSUS TRACT 0 - OPTIONAL O ISUPVISOR - DISTRICT CODE - OPT/ONAL <br /> Z 3 CQJ Z <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 ( <br /> FOROO.i9A-5 <br />