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�... STATE OF CALIFORNIA �..i , •��"�' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> � y <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY (7 1 NEW PERMIT 7 RENEWAL PERMIT CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT Q d AMENDED PERMIT 8'TEMPORARY SITE CLOSUR <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAIAE LTU, CU% INAM F ERATOR <br /> ADDRESS NEARE TCROSS PARCEL#(OPTIONAL) <br /> CITY NAME _ STATEZIPZIP CODE SITE PHONE#WITH AREA CODE <br /> S7rc,✓ C �. <br /> Box <br /> TO INDICATE CpICORPORATNW Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY AGENCY Q STATE AGENCY Q FEDERAL.AGENCY <br /> owmrs <br /> TYPE OF BUSINESS 0 1 GAS STATION 2 DISTRIBUTOR q V RVA0IAN +OF TAN l) <br /> T SITE E.P.A. I.O.+(Ro <br /> Q O FARM Q a PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:, T.FIRST) PHONE WITH AREA CODE DAYS: NAME(LAST,FIRST , <br /> Rai g.` i/l=- ( . t <br /> QNP A WITH APPA <br /> NIGHTS: NA E(LAST,FIRST PMONE+WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> SLLa/e /2_e G; <br /> PWQN9 S WITH ARPA CQQIF <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME - / CAREOFADDRE INFORMATION <br /> U /-LI � C . .e sz7 � d <br /> MAILING OR STR =T ADDRESS EooniNc+M /Q IND/NID�UAL LOCALAGENCY <br /> Q STATE-AGENCY <br /> LOPORATIWQ PMRNERSHPQCWNndGENCY Q FEDERLAGEN <br /> CY <br /> CITY NAME STATE ZW CODE PHONE+NTH AREA CODE <br /> /0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER jsa� CARE OF ADDRESS INFORMATION <br /> r.� A5 � -� <br /> MAILING OR STREET ADDRESS ,/ W#V N Q INDIVIDUAL Q LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNrYAGENGY Q FWERALAGENCY <br /> CITY NAME STATE LP CODE PHONE+WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 71-LL I I —F—F <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Sw V v " Q I SELF-INSURED Q 2 GUARANTEEQ 7 w Q#SURELY SONO <br /> Q 5LETTEROFCRETXT Q B EXEMPTION !OTR <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or It is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O IL In. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME IPRINTEO&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LCCAL AGENCY USE ONLY <br /> COUNTY III � ,5 wlu�, (� JURi�a FACILfTY R <br /> 9 I 0 <br /> LOCATION CODE CENSUS T. -O� SUPVISOR-DISTRICT CODE -OPTK)NAL-� / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> PORM A(5.11) FCROP3A.5 <br />