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�• eon^ <br /> STATE OF CALIFORNIA b • " c°t} <br /> STATE WATER RESOURCES CONTROL BOARD W <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> �•t now N`• <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> 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 /> ADDRESS NEAREST CROSS STREET PARCEL o(OPTIONAL) <br /> !930© C <br /> CIN NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> 74e e .1,�- C CSA <br /> I/ BOX <br /> TOINDIC TE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.O(opticrial) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> !� DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> SI 0 S 3 `7. BY PHONE-A WITH AREA CODE <br /> IGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> V' ct !E 0 2-07 '79 ,714 PHONE#WITH AREA rnnf: <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME f CARE OF ADDRESS INFORMATION <br /> M ILING OR STREET ADD ESS ✓ box toind"m Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Lit N 3 KN C UVI Q U CORPORATION} PARTNERSHIP Q COUNTY AGE`1CY Q FEOERALAUW._Y <br /> CITY NAME • STATE ZIP CODE JPHONE M WITH AREA CODE <br /> N�II�IQ r•� n p 9Z - <br /> III, TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 0 a- 1 IV C_ <br /> MAULING OR STREET ADDRESS ✓ box bindicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 1-f L q 3 (\N C LLV I N , v Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bort toindicate Q 1 SELF-INSUREO Q 2 GUARANTEE Q 7 INSURANCE Q a SURETY BONO <br /> 0 5 LETTEROFCREDIT Q 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ 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) i APPLICANTS TITLE - DATE MONTWOAYNEAR <br /> kV" <br /> PT <br /> Dmtl4p- fig, J�ijagA Wit <br /> LOCAL AGENCY USE ONLY <br /> COUNTY p JURISDICTION A FACILITY# <br /> ❑ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 />