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STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT O 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION E] 7 PER ANENTLY CLOSE <br /> ONE REM 2 INTERIM PERMIT < AMENDED PERMIT Q 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ` <br /> DB OR FACILIF ^ i NAME OF OPERATOR <br /> _C� n_ <br /> AW SZ I I NEAR EST CgOSS STREET PNICELI(OPrDNUJ <br /> CITY NAME 8TCA TT LP" � <br /> v Box <br /> TISITE PLgNEi WITH AREA CODE <br /> OINDICCAATE O CORPORATION �INDIVIDWL O PARTNERSHIP (� LOCALAGENCY COUNTY-AGENCY' O STATE-AGENCY' a FEDERILLAGENCY' <br /> N owner of UST N a pUbNc agency, DISTRICTS <br /> pu :nartr o/Supervisor of 1kbn,section, ' <br /> or office which operate the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR / IF INDIAN Is OF TANAT SITE E <br /> r E.P.A I.D.i NpIkeW <br /> 0 RESERVATION <br /> Q 3 FARM Q A PROCESSOR �5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) I AP1HONE I�TH AR'E DE SYS: NAME(lA3T,FIRST) EPHONE i WITH AREA CODE <br /> 1C_!C• �(J t � <br /> N04TS: NAME T,FIRST) PHONEi WITH AREA CODE��� NMaF1T8: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> 11 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> n e-1 movafOk <br /> MAILING OR STREET ADDRESS II � ^ 1� ✓6owblMOW � 0 NI)UAL LOCAL-AGENCY ED STATE AGENCY <br /> 1'C./✓v��� �--� CORPORATION [:1 P7ARTNEERSSHIP (] CCW/NTYAGENCCYY a FEDDERALLAGENCY <br /> CITU N STATE <br /> - ZIP CODE J 7Y0 PL-ll 1 C A <br /> III. TANK OWNIR INFORMATION-(MUST BE COMPLETED) CODE v-,�QIW �� (!I� <br /> NAME OF OWNER vLa cart �) uo CARE OF ADDRESS INFORMATION <br /> MAILINGO7 RE'E,ADDRES$�� Ved L/l- .1 box bMbW 27MDIVDUAL 0 LOCAL-AGENCY [7]SrATE.AGENCY <br /> W C6 l =CORPORATION = PARTNERSHIP 0 COUNrYAGENCY [7]FEDERAL-AGENCY <br /> CITY NAME G STATE - ZICR3 � PHO��WITH AREA COOE� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER---Call(916)3222-9669 if questions arise. <br /> TY(TK) HO 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Wx binricate = I SELF-INSURED 2 GUARANTEE [-13 INSURANCE Q/SURETY BOND <br /> I]5 LETTEROFCREOIT Q&EXEMPTION =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: 1.0 II. 111.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY IF <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL &NVISOR•DIBTRICT <br /> ,C..ik. 5 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHS IS A CHANGE OF SITE woRmAmWomy. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA 13931 FORO(03AA7 <br />