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STATE OF CALIFORNIA 40 «««aV-cc <br /> STATE WATER RESOURCES CONTROL BOARD i� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ��' "° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE '�; ' <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO ED.SITE �— <br /> ONE ITEM E�] 2 INTERIM PERMIT Q 4 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA FACILITY NAME NAME OF OPERATOR <br /> oOR Pl ac DaLvj <br /> ADDRESS NEAREST CROSS STREET PARCELA OPTI NAL) <br /> S-(.c)o 1449-Li3tpsi /_�D LAV4fibc AOQP <br /> CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> ,,c.a CA I33 n 12acf Ila z o3m0 <br /> ✓BOX O CORPORATION 0 UIDNIDUAL WPARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' =FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'Aownerof USTBapubrnagemycmpleta9lelollowmg:re d supervisor d dWion,sedbn oronie which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR 0 ✓IF INDIAN MOF TANKS AT SITE E.P.A. 1.D.A(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 k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> &LwtmAv9_ "w Z-0310 Dkm o «o <br /> NIGHTS: NAME(LAST,FIRST) P NIGHTS: NAME(LAST,FIRST) A WITH NE M WITH AREA CODE PHONE AREA CODE <br /> s/0 2 y .�r <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 4 (K m <br /> MA IN'G�O'RvS,TREETADDRESS ✓ boxbixkate INDIVIDUAL LOCAL-AGENCY F-1 STATE-AGENCY <br /> 1� paopo CORPORATION 3aPARTNERSHIP ED COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE VICE PHONE p WITH AREA CODE <br /> -rw1P cP T33 0 7rJ z o 7 c <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> b(-IID O <br /> MAILING OR STREET ADDRESS ✓ boxto Mrale INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> A N 0 CORPORATION PARTNERSHIP E3 COUNTY-AGENCY E:1 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P NEA WITH AREA CODE <br /> f33 882-63 a <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 it questions arise. <br /> TY(TK) HQF4 4- -C 10 j 3j7 7Uj' Q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED C 4,/I! JA Jag y`f <br /> ✓box to intliale ED 1 SELF-INSURED [:12 GUARANTEE E:1 3INSURANCE Q 4 SURETY BOND CD 5 LETTEROFCREDIT [::]6 EXEMPTION T 7 STATE FUND <br /> [::]S STATE FUND A CHIEF FINANCIAL OFFICER LETTER O B STATE RIND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 0 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.❑ ll.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'STITLE DATE MONTFVDAYNEAR <br /> DAL.W D to <br /> LOCAL AGENCY USE ONLY <br /> COUNTY A JURISDICTION M FACILITY 9&Vp 7/l <br /> m 2-3 Lj a3 11 8 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPT70NAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 91118197 <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 /> FORMA(8-95) <br /> OWNER MUST FILE THIS FORMf THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU STORAGE TANK REGULATIONS <br /> a-I,- q`gIIll � /�I <br />