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egOUn <br /> f <br /> STATE OF CALIFORNIA �P. ' �O <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> yy UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a��� a <br /> �D <br /> /4 COMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM E::] 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Soo I_C) <br /> CITY NAME1L ` ✓(� STATE4 ZIP CODE SITE PHONE#WITH AREA C� s3v os 3 OD <br /> - <br /> I/ BOX <br /> TOINDIC TECORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY (]COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATIO <br /> ;T;� <br /> 3 FARM 4 PROCESSOR 0 5TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) optional <br /> DAYS: NAME LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> c.Ic Zed 3--03k/ <br /> NIGHTS: NAME(LAST,F ST) PHONIE7#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Z r - 7y- 3 5 7Z <br /> PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFORMATI <br /> MAILING OR$TREETADDRI(� S C ✓boxbi 'ate E::] INDIVIDUAL E:] LOCAL-AGENCY 0 STATE-AGENCY <br /> a(, SOv M f p✓ q/�'�/4 ItiC 3y�01CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 5WONE#WITH AREA CODE <br /> 0 0 zoo 3y <br /> j - 52-73 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP 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 -lol24717 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION (] 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 /> [CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II.FIII. <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 MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FFFT F5- s <br /> LOCATION CODE -OPTIONAL ^ CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ?v ZI <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS I A E OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FORD033 <br />