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F50UR[ES <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3 , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> Tyr , o <br /> COMPLETE THIS FORM FOR rLACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT __i 3 RENEWAL PERMIT ?-r CHANGE OF INFORMATION n 7 PERMANENTLY CLONE ITEM i 2 INTERIM PERMIT 4 AMENDED PERMIT TEMPORARY SITE CLOSURE <br /> �__ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> RESS ' N PARCEL#(OPTIONAL) <br /> vo YO Is 4 All <br /> CI. M � ^ STATE ZIP CODE SITE��"1 ON���H AR C9p <br /> - -------- - - -- - - 5 <br /> ✓ BOX INDIVIDUAL]CORPORATION ! �� PARTNERSHIP �� LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY <br /> TO INDICATE 7 -� FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION L—_] 2 DISTRIBUTORR SERVATION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> CY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE_ <br /> 2 111 <br /> NI ME(LAT,FIRST) PHONE#WIT / NIGHTS. <br /> CODE <br /> II. PROPERTY OWNER INFOR ATION• MUST BE COMPLETED <br /> NAME RNtff IfAR 1— / CARE OF ADDRESS INFORMATION , <br /> MAILING OR STREET ADDRESS P. <br /> 0 , f3191/ -12-50- ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> r ORPORATION PARTNERSHIP [] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME / c / A /_ ` n STc� ZIP!2E � PHONE�0TH A�A Civ E H o t <br /> if <br /> III. TANK OWNER INFORMATION-(MUST f_BEE COMPLETED) 5 8 YO—Hot <br /> (L <br /> NAME OF OWNER 6tt4 q /�/ /W e CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ^�- ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> Y [ CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME �_ //�� �� STATE ZIP C ` PHONE WITH AR,a C�E S <br /> /.J`/l r1/ � J Z O— b � �' <br /> IV. BOARD OF EQUALIZATION UST +STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 14 i- b-L�- T9�.� � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE L� 3 INSURANCE J�� �( l 4�SBON <br /> /�JRETY D <br /> 5 LETTER OF CREDIT L_J 6 EXEMPTION L] 99 OTHER �//���-/ - l <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. IL III. , <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/DAY/YEAR <br /> LOCAL AGENCY USE ONLY 11 <br /> COUNTY It JURISDICTION It FACILITY 4'a 1 <br /> 3 9i21� I_Z <br /> 4'L701ATI17NC_CDE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Ar-, JA 11 Aj. <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 STO�TANK REGULATIONS <br /> FOR0033A-R6 <br />