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sOV• � <br /> STATE OF CAUFORNA •� <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> W m� n' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A >, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE °a�.o„.�- <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILI NAME NAME OF OPERATOR <br /> ADDRESS �+ IN TCCR,rO�SS�E-T.RE PARCELa(OPTI01U4 <br /> CITY NAME L STATE ZIP CODE ITE PHONEa WITH REA CODE // <br /> CA 4767O 9 96 — 7/VF5 <br /> T 1NDICAT <br /> 0E 0 CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL'AMNCY 0 COUNTYAGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTPoCTS' <br /> N owner of UST Is a public agency.conplate the following:nal of Supervisor of division,section,or oflim which operates the UST <br /> TYPE OF BUSINESS a i GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN lal OF TANKS AT SITE I E.P.A. I.D.a(cprbW) <br /> RESERVATION <br /> 0 3 FARM O d PROCESSOR r, <br /> OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optimal <br /> DAYS: NAME(UST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ] <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS:NAME(LAST.FIRST) PHONE As WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMCARE OF ADDRESS INFORMATION <br /> ..�/ ITL r _ J <br /> MAILING OR <br /> STREET ADDRESS ✓ bss tobSsaro 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUKrY-AGENCY 0 FEDERAL-AGENCY <br /> CITU NAME STA ZIP CODE HON •WI AREA CODE <br /> [� GJ Tor /oAv87-/ 7Z <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME OF O R CARE OF ADDRESS INFORMATION <br /> -/Yjq V), �r" Fe?cS 4u <br /> MAILING OR STREET ADDRESS ✓box birdl 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTYAGENCY O FEDERAL-AGENCY <br /> CITYNAM STATE ZIPCODE PHON aWITH AREA COOS <br /> � fl93�r—(DAs ?/ 7 -172 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-T4--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bYdiam, 0 1 SELF-INSURED O 2 GUARANTEE (] 3 INSURANCE O 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION O 99 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: LO IL 111.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED S SIGNED) OWNER'STTTLE DATE MONTHIDAVtVEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY is JURISDICTION• FACILITY t <br /> LOCATION CODE OPTIONAL CENSTACTa OPTIONAL S��jR-DISTRICT 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 OILY, <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) /L A FOR000MV <br />