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typVe � <br /> STATE OF CALIFOFNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> � C <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT F__j 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) T <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Vo C& rl_L2__ CA <br /> ✓ BOX <br /> TO INDICATE C]CORPORATION [ INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY [j COUNTY-AGENCY E::] STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS X 1 GAS STATION U 2 DISTRIBUTOR R SEIF RVATIONj#OF TANKS AT SITE E.P.A. I.D.#(Aplional) <br /> 3 FARM � 4 PROCESSOR � 5 OTHER OR TRUST LANDS I C Q C' <br /> 42 V <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) S� PHONE#WITH AREA CODE DAYS: NA E(LAST FIRST) / �U�J) a / p� <br /> _6&//91 o 1_ 0 C KY..J — 36�?o� � /LC!CT Tc ola �� // p�/ONF r(� ITH A`REEACCOD/E_ <br /> NIGHTS: NAME(LAST, IRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) _ -aIs <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> D/2 .5/ /)1=_:. <br /> MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL <br /> _ � LOCAL-AGENCY � STATE-AGENCY <br /> C- 'oZ 5 k v CORPORATION E�j PARTNERSHIP E:j COUNTY-AGENCY El FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> % <br /> MAILING OR§TREET A DRESS l ✓ box ID Indicate tq INDIVIDUAL <br /> [] LOCAL-AGENCY [] STATE-AGENCY <br /> O CORPORATION [] PARTNERSHIP [] COUNTY-AGENCY E] FEDERAL-AGENCY <br /> CITY NAME STATE ZIPJ�,ODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE AC <br /> COUNT NUMBER-mlau � <br /> cnsc "3-9555 if questions arise. <br /> TY(TK) HQ �4 14-1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILIT IFY THE METHODS) USED <br /> ✓ box to indicate 1 SELF INSURED �V `'\� (`�� [j 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT L:j 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRES; �tt_.I/-� _ to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE I v1�'� �J i��l ` <br /> THIS M HAS BEEN COMPLETED UNDER PENAL'I Y OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> PPLI A 'S AME RINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAV/YEAR <br /> �----- rC <br /> CAL AGENdY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# r( O <br /> a3 / 1-2 ��y <br /> LOCATION CODE .OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> O /0/7)l9& <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO MATION bNLY. <br /> FORM A(5-91) FOR0033A-5 <br />