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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE U <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELa(OPrONAO <br /> aA D 5/ - 3Zo - 07 <br /> CITY NAME STATE ZIP CODE SITE PHONE WITH AREA CODE <br /> CA I d:=)5 93 <br /> TO I/ BoxTE CORPORATION O INDIVIDUALRT <br /> O PARTNERSHIP LOCAL-AGENCYO COUNrYAGENCY• 0 STATE-AGENCY' 0 FEDERAL#GENCY' <br /> DISTRICTS' <br /> •N owner of UST Ie a public agency.oonplete the following:name of Supervisor of division,section,or oNim which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> IF INDIAN is OF TANKS AT SITE I E.P.A. I.D.a(1plbn a# <br /> ❑ 3 FARM ❑ 4 PROCESSOR QSq 6 OTHER OR TRUST LANDS / <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•opdmW <br /> DAYS:NAME(OAST,FIRS ,�\PHONNE#WITHAREA TH COO DAYS: NAME(LAST,FIRST) PHONE s WAREA CODE <br /> .i A✓li 727 —7 HA <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA RUDE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 _S`�T�,/ir—�Af <br /> MAILING OR STREET ADDRESS ✓box tkdo 0 INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> ,40.' p CORPORATION 0 PARTNERSHIP 0 COUNTYAGENCY 0 FFDERAL-AGENCY <br /> CITY NAME � STA ZIP CODE PHONE a WITH AREA CODE <br /> ..y.. _[- <br /> I / G / <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boabinElale 0 INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> 2v/,pd4jAv- <br /> CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE TZIP CODEPE: <br /> ;a ITH AREA CODE <br /> v 0 Z' 7 ,� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322.9669 if questions arise. <br /> TY(TK) HQ F4-14--]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE MEMOD(S) USED <br /> ✓ boy b i�Mvale O f SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY SONO <br /> (]5 LETTEROFCREOT O 6 EXEMPTION O gP OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is chocked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.I] II.❑ 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 S SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTU 10 19 161 /1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -CPTOOAfAL --Ts—up—VISOR-DISTRICT CODE -OP770ML <br /> Z�3.63? 1 S40 <br /> TW 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 REGULATIONS <br /> FORMA(3931 FOR6fO3AA7 <br />