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e <br /> gOl1R E <br /> STATE OF CALIFORNIA Ae P �Oa <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Fa . �0' <br /> fT •OSI If oP N•f <br /> COMPLETE THIS FORM FOR EACH FACILfTY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F—] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM LE 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FAC(L�NAME NAME OF OPERATOR <br /> ADDR SS,/ J - p NEARPT CROSS ST PARCELp(OPTIONAL) <br /> ZE <br /> CITY NAME ter/ STATEZIP CO SITE PHONE#WITH AREA CODE <br /> LvDZ <br /> CA � - <br /> TOINDCATE CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS 10 <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN #OF TAN AT SITE E.P.A. t.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME LAST,FIRST) ��� E#WITH RE ti D�, DAYS: (LAS�T•'FIRST) �� / �j^ O b <br /> NE#WITH AREA GO <br /> NIGH: NAM_ AST, IRST) P�NF#WITH AREA CODE <br /> NIGHTS: NAMnzv/SEE(LLAAST,FIRST) PHONE#WITH AREA i"Mr: <br /> &�fKa� <br /> II. PROPP./ERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME P.P.Lwo"L CARE OF ADDRESS INFORMATION <br /> !/ <br /> MAILING RSTREETADDRESS ✓ box bindicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STAT ZIP CODE 7 6j�j WITH AREA CODE <br /> DIE zl� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME O OWNER CARE OF ADDRESS INFORMATION <br /> _rte ©4&_ eAj✓ G�nl-� , k a&.&r <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME � ` � STATE ZIP CO�� 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 L 4 J-Lj <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate _ ] 1SELF-INSURED 2 GUARANTEE <br /> 3 INSURANCE E:14 SURETY BOND <br /> L-J 5 LETTER OF CREDIT 6 EXEMPTION L-199 OTHER <br /> 71 <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: I.E II.BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. It. <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 MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOC CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL C•T. Q [(T C <br /> Z3- � f- v <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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> T16 <br />