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�50UR[e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY rv1 NEW PERMIT n 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM n 2 INTERIM PERMIT L] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R FACILITY NAME W`,QS NAME OF OPERATOR <br /> ADDRESSREST CROSS STIR #(OPTIONAL) <br /> NE <br /> ,44AoS' FNC, CA 1A <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stv�r2'4 CA <br /> ✓ BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL = PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY [] STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORRESE F INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM 4 PROCESSOR Vr5 OTHER OR TRUST LANDS Z_ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) r D PHONE#WITH AREAvlC'ODE�/� DAYS: NAME <br /> E((LAS,T,,FIRST)/��(.� ��— <br /> TI�D 1G R Ae O 7O -�iJ(/� Of 1 /�V ��7/ / / PHONE#WITH AR A (n <br /> HTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE N HTS: NAME(LAST,FIRST) , as y 9 -7- 66 <br /> T SFi�'R v9 ��3-�a'y 5'l 7�Iiy/ <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM &6 CARE OF ADDRESS INFORMATION � SoLE Q <br /> MAILING ORSTREET A PRREEESS ✓ boxncae = INDIVIDUAL LOCAL-AGENCY <br /> n biditSTATE-AGENCY <br /> �— �C/��(i v�� CORPORATION 0 PARTNERSHIP [] COUNTY-AGENCY E::] FEDERAL-AGENCY <br /> CITY dv /J TE ZIP CODE PHONE#WITH AREA CODE v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> N RF Qvv CARE OF ADDRESS INFORMATION <br /> f-i /� [o' :5.A-,r <br /> ,eoP <br /> MAILING OR STREET DRESS i ✓ box b indicate 0 INDIVIDUAL LOCAL-AGENCY <br /> [� STATE-AGENCY <br /> ��O��F�� kV 0 CORPORATION ] PARTNERSHIP COUNTY-AGENCY [D FEDERAL-AGENCY <br /> CITY NAME S ZIP CODE PHONE#WITH AREA CODE <br /> S?"ocieTv� 9So2o <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4T4 <br /> J- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> C� 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: I. it.� III. <br /> THIS FORM HAS BEEN COMPLETED UNDER P ALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATUR APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> sT AJ E tJ, - - 9 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> _- - - ' <br /> LOCATION CODE OPTIONAL I 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(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br />