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we z <br />STATE Of CALIFORNIA� o <br />STATE WATER RESOURCES CONTROL BOARD W nom' Ae o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A . ; <br />COMPLETE THIS FORM FOR EACH FACILITYISITE °"'°""�� <br />MARK ONLY <br />O t NEW PERMIT <br />3 RENEWAL PERMIT <br />5 CHANGE OF INFORMATION E <br />7 PERMANENTLY CLOSED S ITE <br />ONE ITEM <br />Q 2 INTERIM PERMIT <br />Q 4 AMENDED PERMIT <br />Q S TEMPORARY SITE CLOSURE <br />X <br />nnnn rw ICT ee n(UAOI CTCNYY <br />I. rALd LIIT1QIIC M�V <br />PHONE a WITH AREA CODE <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE #WITH AREA CODE <br />O <br />ADDRESS <br />NEAREST CROSS STREET PARCELa(OPTIONAL) <br />32� S. � �c.�o✓1 <br />X <br />CITY NAME <br />STATE <br />ZIPCODESITE <br />PHONE a WITH AREA CODE <br />CA <br />53 G6 <br />/7c- <br />s36� <br />,( <br />✓ �x I�pRPORIRr N_ (] INDIVIDUAL O PARTNERSHIP Q LOCAL COUNfV-AGENCY' O STATE -AGENCY' FEDERAL -AGENCY' <br />I/ Box LOCALDSTRIGE <br />T <br />' 6 owner d UST is a public agency, complete the following: name of Supervisor of oNisbn, section, a office which operates the UST <br />TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR <br />= <br />1# OF TANKS AT SITE <br />E. P. AL I. D.a (op Hanel) <br />RESERVATION <br />Q 3 FARM Q 4 PROCESSOR THER <br />OR TRUST LANDS <br />cncnneunv MWAM ORGenN IgGIMABYt EMERGENCY CONTACT PERSON (SECONDARY) - ootlonal <br />DAYS: NAME (LAST, FIRST) <br />PHONE a WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE a WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE #WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) <br />PHONE 0 WITH AREA CODE <br />o ee I'MAMI [TCM <br />NAME <br />-- <br />/ <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET AD DRESS <br />✓ Ib4 bindbate O INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />X <br />E:1 CORPORATION O PARTNERSHIP COUNTYAGENCY 0 FEDERALAGENCY <br />CITY NAMESTATE <br />ZIP CODE <br />PHONE a WITH AREA CODE <br />/7c- <br />s36� <br />,( <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAMEOFOWNER CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS ✓ box blMbeN INDIVIDUAL O LOCAL -AGENCY Q STATE -AGENCY <br />[] CORPORATION [] PARTNERSHIP O COUNTY AGENCY D FEDERALAGENCY <br />CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322.9669 it questions arise. <br />TY (TK) HQ F4 -F4--] - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) —IDENTIFY THE METHOD(S) USED <br />✓ �T bNdkaM O I SaRNSURED 0 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND <br />D 5 LETTEROFCREDIT O 6 EXEMPTION I�THER <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 />CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II, III. 0 <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />OWNER'S NAME (PRINTED 3 SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY IT JURISDICTION # FACILITY # <br />17-1311 ! <br />LOCATION CODE -OPTIONALCENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ! r_pY - <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESSTHS IS A CHANGE OF SITE INFORMA71ON ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORMAl3le31 � � ✓^ // ���� � FORW73AA7 <br />