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f <br /> STATEOFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3„ffi <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY I NEW PERMIT Q 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q t AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME n NAME OF OPERATOR II IV <br /> C-Cr UJhoc-c_JC S�-a'{�o✓� Ol"L'� IJnocel Corporo,+ion <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(ORIONAU <br /> 1 b 3 {' CL +rj 1� Sk re-e+ to J <br /> CITY NAME STATE ZIP CODE SITE PHONE#WRH AREA CODE <br /> BOX <br /> CA nt,9 <br /> T NDICATE COPPOAATION Q INDIVIDUAL Q PARTNERSMP Q LOCAL AGENCY Q COUNTYAGENCY' Q STATE-AGENCY* Q FEDEMLAGENCY' <br /> DSTRCTS' <br /> •N tamer d UST Is a pWic agency,moplele the toloMng:nen of Supemisw d dNisIon.sanbn,W drive a Ich g etwee the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A I.0.#(cp!/mag <br /> TO(Y`nEf/ O PROCESSOR 5 OTHER RESERVATION <br /> S FARM a } <br /> O � Oft TRUST LANDS � J <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA COO E DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Ed Ralsl�n S/o-Z ?-Z3( l IVI <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Weeks Fc Fak 0 T1 ank �j- Ar+kur f'JcrboA�r <br /> MAILING OR STREET`ADDRESS ,,,✓,box Ia WdeaY Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> I 1 t S r^U Tres St 22 Poo r- IJP/GORNMTION Q PARTNEASMP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> San F�aY�c eco G� 9L//(7 �/1 —39(s-310D <br /> III. TANKOWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Uoc C,or o6dwarc( Rc,­15+ Y% <br /> MAILING OR STREET ADDRESS ✓ ts,hiMit4 Q INDIVIDUAL Q LOC <br /> M-AGENCY STATE-AGENCY <br /> 1d00nG4ow /wAJYLYIGGoM �D d �CppRMA ON Q PARTNERSHIP Q CAUN YAGENCY fEDEMLdGEN <br /> CYtSV1 <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Say, �OLw.oY. cA4 �tyS83 sto- z�-�--Z-3+61 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓mieNytye Q t SELF-INSURED Q 2 GUARANTEE Q 1 INSURANCE Q a SURETY BOND <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPTION Q 90 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: L O II.a U. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERSNAME(PRINTED6 SIGNED) D �AL$Ta sJ OWNER'S TIRE DATE MONTHADAYNEAR <br /> QQ Sk. EUJ, UEb"C,15T <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Is FACILITY tit } GG 72&E <br /> m FS I 5-0Yo 1fk <br /> LOCATION CODE -OP17O L CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICTCODE -OPTADNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM BI UNLESS THIS IS A CHANGE OF SITE tNp R Txm O� Y. <br /> FORM A(3OWNER MUST RLE THIS FORM WRIONSH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATx931 <br /> r TI5� I �L��J, <br /> r� <br /> 1 <br />