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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FOFm;-A— ew <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY i NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 'CLOSED.SITE ^'l <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE: L <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) F E r It <br /> DBA F I TY NAME Mr <br /> ERATOR <br /> ntia h ► P - Tra <br /> ADDRESS NV4REST CROSS STREET U UIAPICEL#10PTIONAL) <br /> S u1. 10 <br /> CITY NAME STATE ZIPAODE ITE PHONIEN WITH AREA�C]QE0 <br /> CA S3 /1/ <br /> ✓BOX O CCRORATION 0 INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O CO(NR1'-AGENCY' C� ATE-AGENCY- � FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS /` <br /> Ia 01uST Hapublicaganry,CmVWletMIolbwng:nwra of supemsor of dwision,Wien wofm which op WaNe UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTORO ✓IF INDIAN NOF TANKS AT SITE E.P.A, I.D.N(0Xhmmp <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> V : (UST,Fl T) ONE N WITH AREA COD D : NAME( T,FIRS ON IT)fj>fjOp�(�` <br /> L <br /> - - Ie if h b6�� ��ff r 14 <br /> NIGHTS: NA ST,FIRST) w ISHONVIWITHAREAC PE N/lIfiH : N E KAST,FIRST) O N Di AREA CO= <br /> RMA <br /> II. PROPERTY OWNER INFOTION-(MUST BE COMPLETED) <br /> NAMI�_ ei CARE OF ADDRESS INFORMATION <br /> MAILII`N-'G{P TREET ADDRESS A ✓ bpzbidrate ED INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> 0. 1 y 2 f.1 CORPORATION I=PARTNERSHIP O COUMY-AGENCY FEDERAL-AGENCY <br /> CRY NAME STATE ZIP CODE ' P ONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l/��a <br /> NAMED OW ^ � CARE OF ADDRESS INFORMATION <br /> 1 '1 <br /> MAILING OR STREET ADORES �//s,`, (�, ✓ bexIDh*is O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> -1-l2 7J O CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CT'NAME STATE ZIP CODE �' PHONE N WITH AREA CODE_ O <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322---9669 if questions arise. S LHr/ <br /> TY(TK) HQ F474- - <br /> f1" <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓EmbkdcWSE1F-INSURED O 2 GUARANTEE Q 31NSURANCE O 4 3uRETYBONO ED 5 LE TEROFCREDIT 0 6 EXEMPTION O r SrATEFUND <br /> X..STATEFlINDBCHIEFF6UNOALOFFICERLETTER =a STATE FUND&CERTIFICATE OF DEPOSIT O 16 LOCAL GOVT.MECHANISM = N 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 11. III.O <br /> THIS FORM HAS BEEN COMPL UNDER PENAL OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OyYf IERS E(PRINTED&SIGN n TANK OWNER'S TITLE DATE MONTHICAYNEAR <br /> L ,ter -.z3-W <br /> LOCAL AGENCY USE ONLY Q/y\ / <br /> COUNTY N JURISDICTIONN FACIL�LJy�/ J(�/�(Q <br /> LOCATION CO -OPT70NArONIALL�-j-)11 CENSUS TF: C -OPTIONA SUPVISOR-DIST CT ODE -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 FORi� �H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRC ',STORAGE TANK REGULATIONS <br /> FORMA(6.95) 7'� N'T4V-7-100 106 <br /> If— -I — C90 <br />