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3 6"t <br /> STATE OF CALIFORNIA <br /> 3 STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITIE 6ITN+. <br /> MARK ONLY <br /> 1 NEW PERMIT E-13 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED„SI <br /> v-� <br /> ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 10A9— 5a3 3 8% <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS ' W�F9 NEARCa�C PARCEL#(OPnONAL) <br /> CRY NAME /-�Q��� / STATE ZIP cc” W EA CODSITE PHONE <br /> \J �1// CA ,3 Z-C 2 ✓z <br /> ✓BOXCORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNIY-AGBCY• Q STATE-AGENCY• Q FEDEML-AGENCY• <br /> TO INDICATE Cp� 015TRICTS <br /> 80.mr d USTca ptbk agcy,mnpleM ft TOLOwiq.dwpr d Wmm,srmon a.a.xluiiaPardas Ne UST <br /> IFINDIAN TYPE OF BUSINESS' Q T GAS STATION 0 2 DISTRIBUTOR r� IQ gESERVATON P OFJANK$/nA�T SITE E P.A L//D)).#(optianaq <br /> Q 3 FARM Q 4 PROCESSOR c 5 OTHER OR TRUST LANDS //`/'�'l./� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS NAME(VST,FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2 5v52pt1,,7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIG14TS: NAME MST,FIRST) PHONE#WITH AREA CODE <br /> c � cC C � n <br /> II. PROPER OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR SYhEET ADDRESS ✓ Dodo d= Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> 1Oi1PORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERA.-AGENCY <br /> CRY NAME✓` /�� P CODE _ <br /> MAVI/_ /j,,2O2- uN5-?; � <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER -'' CARE OF ADDRESS INFORMATION <br /> MAILING OR017FLEET ADDRESS ✓ Em to iiS�la Q WOMDUAL Q LOCAL-AGEN.Y Q STATE-AGUICY <br /> .[-- J ORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME ,/� STATE, ZIP COOE�a2 PHONE PWIf AREA ;O Oo- <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3222-9669 if questions arise. 3 S <br /> TY(TK) HO 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓m>I ro'vr4aie Q 1 SE14MRED Q 2 GUARANTEE ED3 1NSURANCE Q A SUAETYBONO Q 5 LETTEROFCRmiT Q 6 0MMMMNQ T STATE FUND <br /> Q 8 STATE NAN <br /> FUND CHIEF FINANCIAL OFFICER LETTER Q 9 STATE RIND&CERTIFICATE OF DEPOSIT EDIOLDCALGOVT.MEOHN4S11 Q 990THER <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 81LUNG L.ED ILL III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BESTOF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNERS TITLE DATE MON7WtlDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCA-TION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPITONAL 7A <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />