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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A , Sf Gip` <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE `""°""'•. i�It',1 l <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE ryL <br /> ONE REM Q 2 INTERIM PERMIT Q A AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE J U ) <br /> I. FACILRYISITE INFORMATION 6ADDRESS-(MUST BE COMPLETED) �f�Av/9� <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Tgx�co icy, <br /> ADDRESS NEARESTCROSSSTR T I PARCEL 0(OFTIONAU <br /> `41- <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Trot <br /> CA 19673j -4+544 <br /> T N BOX M CORPORATION CD INDIVIDUAL O PARTNERSHIP 0 LOCALAGENGY 0 COUNTY-AGENCY' O STATEAGENCY' 0 FEDERAL-AGENCY. <br /> DISTRICTS' <br /> •I owner el UST Is a Public agency.mntP109 the 1010M g:nam of Supmrc or of dNlsim seotbn,or office which operates the UST <br /> TYPE OF BUSINESS � 1 GAS STATION 2 DISTRIBUTOR R SERVATIIOONN eOF TANKS AT SITE E.P.A. I.D.#(nPllanal) <br /> 3 FARM 0 a PROCESSOR L__] 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optlonel <br /> DAxS: N ME(LAST.FIRST) PHONE S WITH AREA CODE Y3:NAME(LAST.FIRST) PHON #WITH AREA CODE <br /> Ciri J�odha �`Iith Cion 5okid Nic1� coq 3-zo!( <br /> NIGHTS: NA EM (LAST.FIRST) PHONIER WITHAREACOOE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME (rI B- 4, AXE N <br /> ./� A/aTCL.. CARE OF ADDRESS INFORMATION <br /> MAII`LII�NGG OR STREET ADDRESS ✓bosbIntleft 0INDIVDUAL LOCAL-AGENCY 0 STATE AGENCY <br /> z j 10.. R V O CORPORATION O PAIRNERSMP O COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAMESJ�1TFf ZIP PHONE a WITH AREA CODE <br /> =—f LVA 9OD <br /> III. TANK OWNER INFORMA ION-(MUST BE COMPLETED) <br /> NAM J:OF�0 1 B. <br /> III, A.F, -,A`II ou axm– CARE OF ADDRESS INFORMATION <br /> MAILING--NrGG OR1IlISTRY4EEEET ADDRESS ✓ 6°sbkdIcAm 0IN04VIDUAL 0 LOCAL AGENCY Q STATE AoENCY <br /> zsocx;� ri � oa t O CORPORATION D PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGEWY <br /> CITY NAME �.— STATE ZIP ODE PHONE#WITH AREA CODE <br /> 1n CAS 3--7 <br /> IV.BOARD OF EQUALIZATION UST bTORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- -rp ? 4, l $ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bom bIn kale 0 1 SELF INSURED O 2 GUARANTEE [:13 INSURANCE 0 I SURETY BOND <br /> L11 5 LETTEROFCREDT O 6 EXEMPTION 0 w 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: LE] ILD III. <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 6 SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION* FACILITY#J3 D/O . <br /> ❑� C� I-Q3 / 139a v17 <br /> LOCATION CODE -OPrOWL CENSUS TRACT# -OPTIONAL SUPVISOR.DISTRICT CODE -OPTIIONAI. <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMITAPPLICATION• FORM B,UNLESS THIS IS A CHANGE OF Sn INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> ronM A INTI <br /> FORo M`7 <br />