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FOUR e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W mom, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> C•I IFp R N,� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY U 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F_� 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME I NAME OF OPERATOR <br /> A M &347 PWs,nm"srar�ovs'Avec - S'T MAWA4EK <br /> ADDRESS NEAREST CROSS S.TREET44 PARCEL#(OPTIONAL) <br /> CITY NAME l, <br /> 7 STATE I ZIP CODE ?� �SITE <br /> PHONE A W TCA 953Y <br /> ✓ Box <br /> TO INDICATE lecoRPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION F7 2 DISTRIBUTOR / IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR = RESERVATION <br /> 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> A )e4:2i 1q4/n/TEn/ /-8c -Aro <br /> -- / <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> f�iN i M/WsMTEAeAjNI �d �'/ <br /> --Yl PHONE#MJITH AREA CODE <br /> Ii. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> /47L4,V7/d 2/efi/i-/Etl> A&V N&-*_711 �WE7Y <br /> MAILIN ORR�STREET ADDRESS F box bindicate = INDIVIDUAL = LOCAL-AGENCY (] STATE-AGENCY <br /> / 11/46 CORPORATION = PARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHO E#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 7T <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> hg74 W Ale, <br /> MAILING OR STREET ADDRESS ✓ x binOcate � INDIVIDUAL � LOCAL-AGENCY � STATE-AGENCY <br /> CE //�/%� �,�/(/C CORPORATION PARTNERSHIP 0 COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE# ITH AREA CODE <br /> ao Z �?!4 !xs v~ E2 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4T4 - ol d I v Ip <br /> V. PETROLEUM UST FINANCIA RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b Indicate 1 SELF-INSURED = 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> L=5 LETTEROFCREDIT Q 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 /> FCHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.a it.001 III.= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP -_ (PRINT SI URE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> ST Al.CO /9&61v-r !a,/"2 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 7 b3 <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 SPE INFOR ATION ONLY. <br /> FORM A(5-91) <br /> FOR0033A3 <br /> 0 <br />