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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> �I a UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILTTY/SITE <br /> MARKONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT s TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO FACILITYNAME CaI pINpMEOF OPER <br /> pTO <br /> ADDRESS /V1LJ1 NEARF$TCRO S ET PARCEL I(OPfXINAy <br /> W 7 ' <br /> CITY NAM STATE ZIP SITE NE#WI AREA CODE <br /> GI/ Box <br /> CA p <br /> TO INDICATE CORPORATION q INDIVIDUAL O PARTNERSHIP � LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY O FEDERAL AGENCY' ' <br /> V DISTRICTS' <br /> N owner of UST Is a PUNC agency,complete the following:nan a of Supervisor of division,section,ar office which operates the UST <br /> TYPE OF BUSINESS 0 I GAS STATION 2 DISTRIBUTOR Q 'ER <br /> IF INDI OF TANKS AT SITE E.P.A. 1,13,1' <br /> la� RESERVAT N <br /> Q 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST D <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMER NTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH A EA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a <br /> NIGHTS: NAME(LAST.FIRS PHO WITH EA CODE J NIGHT& NAIAE(IAST.FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> N CARE OF ADDRESS INFORMATION <br /> AILING STREET ADDR SS ✓ box blMbats INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> (]CORPORATION O PARTNERSHIP (] COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NA ST <br /> ATE ZIP DE P ^0 H A EA 00 ry <br /> 12�J12 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED R <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box b Mute ED INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP E-1 COUNTYAGENCV 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ F4174- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box blMr.Ne O I SELF-INSURED O 3 GUARANTEE (] 3 INSURANCE DAjeUfl4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 S EXEMPTION eB OTHEfl <br /> Y e, <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box or Ls checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.0 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTRIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDK)TION# FACILITY! ti{I�'/ _ <br /> i�19 10101-11 A <br /> 0 s <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVI90R-DISTRICT CODE -OPTIONAL v9 <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 GROUND STORAGE TANK REGULATIONS ylFc7o I-;V3 <br /> FORMA(3 a3) <br />