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l C�0,C W , 7 A!�w4�/� S � <br /> STATE OF ALIFORNIA WIF .P�t ' <br /> STATE WATER RESOURCES CONTROL BOARD 3 . <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A -�� <br /> 4 � O <br /> j� <br /> •C�CIFOP N' <br /> COMPLETE THIS FORM FOR EACH F CILITYISITE <br /> MARK ONLY 0 � PERMIT a 3 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY OSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT T <br /> ' PORARY SITE CLOSURE r} <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPL ) VvV <br /> DBA OR FAC RLTY NAME ej M <br /> 1 f )/ DAME OF OPERATOR i <br /> 41410 - 7A <br /> ADDRESS NEARESTCROSS STREET PARCEL#(OPTIONAL) <br />. Q <br /> VIA t G a-e <br />}I CITY NAME i S ATE ZIP 900E / SITE PHONE#WITH AREA CODE <br /> CA <br /> TOINDIIC TE CORPORATION Q INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY (] STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS = 1 GAS STATION = 2 DISTRIBUTORRESEIF R INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> Q 3 FARM Q 4 PROCESSOR 1�r5 OTHER OR TRUST LANDS <br /> r EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> I r <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH ARTgA CODE NIGHTS: NAM (LAST,FIRST) <br /> PHONE#WITH REA COD <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME - �.► CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box to indicate 177 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION F7 PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III.i.TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS -r- ✓ box to indicate <br /> + /N� O INDIVIDUAL (� LOCAL-AGENCY OSTATE-AGENCY <br /> + CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME S ATE ZIP CODE PHONE#WITH AREA CODE <br /> S Z _ 3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - l401 Al o^4e At k <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> t✓ box b indicate O 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 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 II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> LICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> r <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# qz4 <br /> � alp <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTI QN <br /> Z <br /> THIS FORM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,U S THIS IS A CHANGE OF'SITE INFORMATION ONLY. <br /> FORM A(5-91) <br /> LQ <br /> i <br />