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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w <br /> v <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY t NEW PERMIT [7] 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENT <br /> ONE ITEM Q 2 INTERIM PERMIT [7 4 AMENDED PERMIT O B TEMPORARY SITE CLOSURE s3 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ( t c�SUn rvC <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> lls6sxIfr g/-, <br /> CITU NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> -5 Co CA <br /> TOINDICATE CORPORATION I�INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRITYPE OF BUSINESS O T GAS STATION Q 2 DISTRIBUTOR / 0 RES/ IF INDIAN ERVATION #OF TANKS T SITE E.P.A. I.D.#(apfimap <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONF Y WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) pwnmp A WITH AREA COD <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME A CARE OF ADDRESS INFORMATION <br /> q l �� L <br /> MAILING OR STREET ADDRESS �+ ✓ OAxbMica, I= INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> S 6 pAD2 S- )/7 &A-)w =CORPORATION = PARTNERSHIP COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAMESTA 21P DE PMH#WITH AREA CODE <br /> ok7 ?� 5 z <br /> 3cv 3- zv s <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET-ADDRESS ✓ box bludiuY 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION = PARTNERSHIP O COUNTY-AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. <br /> 4 <br /> TY(TK) HQ 4 Z <br /> -L L `i--�'—'-,�-x�J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ biMkals 0 1 SELFINSURED 712 GUARANTEE L�j 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT O 6 EXEMPTION 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.O II.O III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANPSTITLE DATE MONTH/DAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL -^—� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGEOF SITE I�ONLY. <br /> FORM A(5-91) F7 <br />