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PeSp,V RC-s C <br /> o STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> y. o <br /> C�[IFOP Nor <br /> COMPLETE THIS FORM FOR EACH CILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM El 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) P—co C( <br /> DBA R FACILITY NAME ^ . ', NAME QF ERATOR <br /> C 1, t{/"�// o c <br /> ADDRESS © jVEl NEARESTCROSSSTREET PARCEL#(0 IONAL) <br /> CI NAME STA E ZIP ODE SIT PHONE#W H AREA CODE <br /> CA /0 S — <br /> ✓ BOX ORPORATION 0 INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N ME(LASTST)sit PHONE#WITH AREA CODE DAYS: NAME(L99S�T,FIRST) Ci860 <br /> NIGHT-4. NAME(LAST,FIRST) PHONE#WITH ARCA CODE NIG S: NAME(LAST,FIRST) <br /> Co H.iw� aK e ([goo <br /> - � o!.-C3 <br /> PHONE#WITH A <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM , n �j� ' / CARE OF ADDRESS INFORMATION Soil <br /> VAQ, <br /> MAILING ORI-STREL1 ADD R SS ✓ box to indicateIN IDUAL LOCAL-AGENCY = STATE-AGENCY <br /> WdS Q CORPORATION PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CI ^NAJ�1E ST/�TE ZIP O>� PHONE#WITH.AREA CODE <br /> O C/// tJ' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF OWNER CARE OF ADD ESS I FORMATION /, <br /> KIC0 A L I/• (2 -y S /h ' �( o <br /> MAI G OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LO AL-A ENCY - ATE-AGENCY <br /> - O CORPORATION PARTNERSHIP Q COUNTY-AGENCY [:] FEDERAL-AGENCY <br /> CI AME 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_T41-Vo Q O Is Q <br /> V. PETROLEUM UST FINANCIAL-RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate FL;KSELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> = 5 LETTER OF CREDIT 6 EXEMPTION 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: 1.0 II.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) i C APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> no h Eh V. i}ss"s A2v► �- 641 <br /> 3 <br /> LOCAL AGENCY USE ONLY ` <br /> COUNTY At JURISDICTION# # � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -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 /> _01% 7d <br />