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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILfTY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> F� <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OFj.FACIUTY NAM NAME OF OPERATOR <br /> J L.C_ <br /> ADDRESS NEAREST CROS TREET PARCELt(OPTIONAL) <br /> 7S 7 // <br /> CITY NAME STATE ZIP C DE SITE PHONE#WITH AREA CODE <br /> AC CA "3 <br /> ✓BOXC RPORATION 0 INDIVIDUAL O PARTNERSHIP i0 LOCAL-AGENCY COUNIy.AGENCY' O STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> -I 0enarol UST@apuble aWiy,cOWWO IN 101bwT name of supemor 01 dwision,uaion oro#iu w&opa "Ne UST <br /> TYPE OF BUSINESS a 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESEIRVATON #OF TANKS AT SITE E.P.A. I.D.#(oplAon#I) <br /> Q 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECI*DARY)-optional <br /> DAYS:PME(LAST,FIRST) PHONE#WITH AREA CODE DA S: NAME( IRSTI PHONE#WITH AREA CODE <br /> Uma <br /> NIGHTS: NAME(LAST,FIRST)' PHONE#WITH AREA CODE NIGHTS: NAME(UST,FIRST) PH]ONE#WISH AREA CODE <br /> 2C cz� o/ <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> kt <br /> ( C EOFADDRESSINFOR ATION <br /> iA LSSoc G rj✓ boab RIDIVIDUAL f� LOCAL-AGENCY I] STATEAGENCY0 CORPORATION i0 PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY STAB ZIP CODE PHONE#WMH AREA C E <br /> E COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> j: ,Iri-2 <br /> MAILING OR STREET AD SS _ V b x b^tie 0 INOMDUAL LOCAL A1ENCY STATE-AGENCY <br /> L✓ KCORPORATION = PARTNERSHIP COUNTY-AGENCY (] FEDERAL- <br /> AGENCY <br /> CITY N ME STATE ZIP CODE PHONER WITH AREA CODE <br /> L <br /> L4 Olt 1 9!93 76 2a- <br /> IV.BOARD OF ECILIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HO F4_14- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bosbm�Cdle f� 1 SELF-NSURED O 2 GUARANTEE O 3 NSURANCE ED 4 SURETY BOND ED 5 LETrEROFCREDR =6 EXEMPTION L_j I STATE FUND <br /> B STATE RIND&CHIEF FINANCIAL OFFICER LETTER O 9 STATE RIND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 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: i.❑ II.❑ IIIX <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO 774E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S <br /> NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHVDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# 003 Al�{- <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CO DE -OPTIONAL <br /> /. 3 <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. J <br /> OWNER MUST FILE THIS FOP TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRY `STORAGE TANK REGULATIONS I <br /> FORM A(&95) 44ow \AIIIIIIII, <br />