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k r z STATE OF CALIFORNIA �` hP! cctip <br /> 41 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-fORMA <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> MAR ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERM CLOSED SITE <br /> ,x ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Ott . tote. <br /> ADDRESS + NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE 'ZIP C E ONE#WITH AREA CODE <br /> CA <br /> BoX - <br /> TOINDICATE SCJ CORPORATION 0 INDIVIDUAL [�]PARTNERSHIP' 0 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> :. DISTRICTS <br /> TYPE OF BUSINESS Ff! 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. J.D.#(optional) <br /> RESERVATION <br /> "l 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECO DARY)•optional <br /> DAYS: NAME(LAST,FIRST) P"E#WITH AREA CODE DAYS: NAME(LAST,FIRSp� <br /> NIGHTS: AME(LAST,FIRST) {� HO #WITH AREA COO NIGHTS: NAME(LAST,FIRST) <br /> 7/Z I—SPHONE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �o( .r�4- Icer <br /> MAILING OR STREET ADDRESS` /+' ✓ box to indicate INDIVIDUAL -AGENCY 0 STATE-AGENCY <br /> 4 "� " ' 'f4@ CORPORATION D PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> bITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> V k.>tr <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF ER • CARE OF ADDRESS INFORMATION <br /> � .# VA <br /> MAILING ORSTREETADDR S ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> Q r `rt,e O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME` STATE ZIP CODE PHONE#WITH AREA CODE <br /> 9"2 707 ., k-/J <br /> IV.BOARiD OF EUALtZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 �► q <br /> " <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ' <br /> ✓bexbindMate` 0 1 SELF-INSURED �2 GUARANTEE � 3 INSURANCE t 4 SURETYBbND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION e99 OTHER S4-At n <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. I III. <br /> THIS FORM HAS BEEN COMPLET UIEJER PEN LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATUR APPLICANT'S TITLE DATE MONTH/DAYNEAR , <br /> lzo its Cv+ 12.. .x..(„a-r <br /> LOCAL AGENCY USE ONLY <br /> 1j 44 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL ]CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL f. <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) FOR0033A-5 <br />