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t- C <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o <br />COMPLETE THIS FORM FOR EACH FACILITY/S(TE <br />MARK ONLY D 1 NEW PERMIT 0 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 0 7 PERMANENTLY �CI�QE' <br />ONE rrEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />,_T N Cp <br />4a' - Av-G, <br />ADDRESS _ <br />6 7q W. 42A�A/7-LlAj6 k_�. <br />NEAREST CROSS STREET <br />7-2Ak/3LVh <br />PARCEL$(OPTIONAL) <br />CITY NAMEj <br />STATE <br />ZIP CODE <br />SITE PHONE i WITH AREA CODE <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />S3 <br />zc19 K33 —3Lf1� <br />✓ BOX <br />TO INDICATE D CORPORATION =1 INDIVIDUAL PARTNERSHIP (] LOCAL -AGENCY Q COUNTY-AGENCYSTATE-AGENCY- = FEDERAL -AGENCY' <br />DISTRICTS' <br />' It owner of UST Is a public agency, complete the following: name of upervlsor of division, section, or office which operates the UST <br />TYPE OF BUSINESS'Y1 t GAS STATION 2 DISTRIBUTOR <br />% <br />O '/IF INDIAN <br />OF TANKS AT SITE <br />E. P. A. I. D.0 (optional) <br />3 FARM a 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />IS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SPCONDARY1- mama) <br />DAYS: NAME (LAST, FIRST) PHONE 0 WITH AREA CODE <br />S�A16,y X,47Aj 533 - 3 /G <br />DAYS: JAME (LAST, FIRST) PHONE A WITH AREA CODE <br />GILL S Gi Al-b� s/o) �Z9 - 0. 3.3 <br />NIGHTS: NAME (LAST, FIRST) PHONE s WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE M WITH AREA CODE <br />-S4-11vl E <br />E <br />IL PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAI <br />1 <br />CARE OF ADDRESS INFORMATION <br />-�'T£4 C , S co TT ._ <br />/� <br />t7vV�G <br />741--.2 <br />c- S <br />AIL NG RST EET AD ESS <br />✓ box bindiatePORATION <br />LOCAL -AGENCY STATE -AGENCY <br />✓ box loinoicm INDIVIDUAL <br />)E711406011,41_ <br />COR0 PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />ST TE ZIP CODE <br />PHONE x WITH AREA CODE <br />�c <br />J <br />LD9) 93-5--- —3%3 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />GATE MONTWDAYNEAR <br />SAiNAM 70 <br />741--.2 <br />c- S <br />n <br />MAILING O E �DiDGQ �j Oil/ <br />IJW �''V. <br />✓ box loinoicm INDIVIDUAL <br />0 LOCAL -AGENCY <br />� STATE -AGENCY <br />/ <br />O CORPORATION PARTNERSHIP <br />Cj COUNTY -AGENCY <br />= FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE X WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ F474- - <br />Id 011* <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box p indicate O t SELF-INSURED 2 GUARANTEE 3 INSURANCE/ 4 SURETY BOND <br />5 LETTER OF CREDIT 6 EXEMPTION 499 OTHER LANb <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, IIIII. <br />. JC <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 & SIGNED) <br />OWNER'S T(TLE <br />GATE MONTWDAYNEAR <br />SAiNAM 70 <br />741--.2 <br />03 9 <br />LOCAL AGENCY USE ONLY <br />COUNTY tt JURISDICTION # FACILITY # ) <br />� 114-10 -qm � -mad <br />ILOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL SUPVISOR - DISTRICT CODE - OPT)OAW. A— <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SrrE INFOR `WTION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 1 <br />FORM A (3193) <br />211 DI/cj-J ��t <br />