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lit • i <br />STATE OF CALIFORNIA a �i <br />STATE WATER RESOURCES CONTROL BOARD ;am, <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILFYISITE � <br />MARK ONLY rlj1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED SITE <br />ONE ITEM O 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. I-AILALITY/SITE INFORMATION & ADDRESS • (Mt1ST RF (.OUPI FTFm <br />DBA OR FACILITY NAME <br />Rf)SEA1 . SAN Rist, R`l <br />CARE OF ADDRESS INFORMATION <br />NAME OF OPEflATOR <br />god C%A(W <br />Pas &rJ <br />AYE <br />a q 50. s� ck'Tp N ST <br />Y <br />CITY ME <br />NEAREST CROSS STREET <br />PARCEL IOPTIONALI <br />. <br />• a? / / <br />Ssca�, S -f-, <br />= COUNTY -AGENCY Q FEDERAL -AGENCY <br />C NAME <br />►Io�J <br />STATE ZIP CODE <br />CA 953196 <br />SITE PHONE WITH AREA CODE <br />d -•599-37i,s <br />I/ BOX <br />TOINDICATE D CORPORATION INDIVIDUAL O PARTNERSHIP <br />0 LOCAL -AGENCY E71 couNTY-AGENCY <br />O STATE -AGENCY O FEDERAL -AGENCY <br />a s <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION El 2 DISTRIBUTOR'/ <br />IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (o tmi l) <br />3 FARM O 4 PROCESSOR Q 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />ovicnuCIYM1 VUIVIAGI rtnsuN (PKIMANY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) <br />W �o9-599-1-7IJ— <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA G( E NIG TS: NAME (LAST, FIRS <br />f> rn osw ao9- o/-,3 5(tooL MAO -SW ao9-s-4 -3�i <br />11. PROPERTY OWNER INFORMATION- IfMUST BE COMPLETED <br />NAM <br />CARE OF ADDRESS INFORMATION <br />'^ ..— .1. U!TINDIVIDUAL <br />[ � � <br />C.VV <br />STATE -AGENCY <br />Y <br />CITY ME <br />MAILCINIG OR STREET ADDRESS <br />V6 <br />✓box blMkate INDIVIDUAL <br />LLOCALAGENCY O STATLAGENCY <br />• a? / / <br />0 CORPORATION = PARTNERSHIP <br />= COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITYVE E <br />�N <br />S TE <br />�f17536 <br />ZIP ODE <br />x 3 6 6 <br />PHONE # WITH AREA CODE <br />—S-34 <br />a s <br />6 <br />--5 - Sgf)s <br />a?O 9_S_99_ <br />�n uavnnlnllvrv- <br />OF ADDRESS <br />A <br />'^ ..— .1. U!TINDIVIDUAL <br />= LOCAL -AGENCY <br />STATE -AGENCY <br />Y <br />CITY ME <br />0 CORPORATION <br />S TE <br />0 PARTNERSHIP <br />ZIP ODE <br />0 <br />COUNTY -AGENCY <br />PHONE#HA <br />WIT <br />0 FEDERAL -AGENCY <br />CODE <br />1 iP(7aJ <br />x 3 6 6 <br />—S-34 <br />a s <br />a -- --• •••– –•--+–'•-•- .a.,. vlvnnwc roc Mwvuly I INumotn - Lull (ylb) 3Y3-9bbb It questions arise. <br />TY (TK) HO 4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ bor bintlicale 0 1 SELF-INSURED <br />!� GUARANTEE 1✓—INSURANCE q BURET <br />5 LETTER OF CREDIT � EXEMPTION [ON OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I 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 />e <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />I <br />LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-❑ISTRICT 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) <br />FOR00.73A-5 <br />