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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W � a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT F75 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM a 2 INTERIM PERMIT 4 AMENDED PERMIT F-1 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> n)RA ORYFCILITY NAME— NAME OF OPERATOR _ (' <br /> JTv . <br /> ADDRESS tNEAREST CROSS STREET PARC #(OPT AL) <br /> 2 Ll ZV tAl- G. 1,v c l os?-c L'. <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> T,,-c,cv CA 9 S7_�- 6 C12 09 6 3 7-6 Z �� <br /> ✓ BOX / CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY <br /> TO INDICATE DISTRICTS' QCOUNTY-AGENCY' QSTATE-AGENCY' QFEDERAL-AGENCY' <br /> I1 owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN IN OF TANKS AASITEE.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) .PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> a e.° ca✓1 y S-3y/2 <br /> NIGHTS: NAME(LAST,FIRST)/ PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS oIndicate LOCAL <br /> -AGENCY STATE-AGENCY <br /> —1 INDIVIDUAL1100 / bo <br /> Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAMESTA ZIP CODE PHONE#WITH AREA CODE <br /> d-a c 6 '2 S S-y y <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> /os,7 ef F6 t <br /> MAILING OR STREET ADDRESS ✓ box to Indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Z y 8 [j�'6RPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD d EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - 0 S <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bIndicate Q 1 SELF-INSURED iQ 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPTION 02'49 OTHER srAt-e FW-,el <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.E if.= III. <br /> THIS!'F M HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> NA E(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> &A <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#3 <br /> m 0 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 76_pVISO R-DISTRICT CODE -OPTIONAL <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. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKklt3 6-?0 � <br /> FORM A(3183) FOR003 {17 <br />