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V.w <br /> .#o� <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE .�® <br /> i <br /> MARK ONLY ❑ 1 NEW PERMIT !tl <br /> ONE ITEM ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION �°„ °- ' o <br /> ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 7 PERMANENTLY CLOSEDSITEI. FACILITY/$ITE INFORMATION&ADDRESS-(MUST BE COMPLETE❑ a TEMPORARY <br /> SITE CLOSURE <br /> DBA OR FACILITY NAME <br /> ADDRESS <br /> NAME OF OPERATOR <br /> // <br /> /?/ • yT�� NEAREST CROSS STREET <br /> CITY NAME PARCEL#(OPTIONAL) lf- <br /> Lo,p STATE LP CODE 1 <br /> v BOX ``A 95� TEPH E#WrrHARE/A CODE 1 <br /> TOINDICATECORPORATION O WDMDUAL CD PARTNERSHIP v9 ?jTs?j-6 <br /> 'Nolmxd USTY aR� 0 LOCAL-AGENCI' (]COUNry-AGENCY' I <br /> aW We De P 0f FFWerviw,dcrmwm. DISTRICTS STATE-AGENCY' QFEDERAL.AGENCY' <br /> TYPE OF BUSINESS #ed'Nn adfee 4kh VO MN 8N UST j <br /> ❑ 1 GAS STATION O 2 DISTRIBUTOR / <br /> ❑ 3 FARM C] ✓IF INDIAN #OF TANKS AT SITE <br /> 0 0 PROCESSOR 5 OTHER RESERVATION E.P.0. I.D.#(opfronat) <br /> EMERGENCY CONTACT PERSON (PRIMARY) OR TRUST LANDS <br /> DAYS: NAME( T,RRsn EMERGENCY CONTACT PERSON (SECONDAR <br /> -t'fA HONE WITH AREA CODE Y)-optional <br /> 333-6 DAYS: NAME(LAST.FIRST <br /> HT!:AME(lA T,RR$1) PHONE#WITH AREA CODE <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME <br /> a boo CARE OFgDORESSINFORMATION <br /> MAILING OR STREET ADDRESS <br /> /-• a• d GTJ ✓ 0a#b Yldrale WDMWAL <br /> 3 l3 CORPORATION OCAL FGQDy �STATEAGENCY <br /> FEDERAL-AGENCY CITY NAME O pAgTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> L420 STATE LP CODE PHONE N WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS r box to htlkme <br /> P. 3r6 O WDMWAL L�LOCAL-AGENCY O srATE-AGENC <br /> CITY NAME O CORPORATION Q PARTNERSHIP hl�CWMY.AGENCy (] FEDERAL-AGENCY <br /> Lv� STATE ZIP CODE HONE WITH AREA COg E <br /> a4 rg2y/- /L-irV ZC � 333- b&2c� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 5-1-4-1- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD($) USED <br /> ✓yy`p I71 1 SOF-INSURED Q 2 GUARANTEE Q 3 INSURANCE =A SURETY BONG O 5 LETTEROFCREDR O B EXEMPTION 0 7 STATE FUND <br /> =8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER a 9 STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O MOTHER <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. 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 MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#0078a <br /> m o % ���19� <br /> LOCATION CODE-OPTIONAL CENSUS T# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0;_ 23 �,v 'z 3 48 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE F SITE iNFbRiAATION ONLY. <br /> OWNER MUST FILE THIS FORMWITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI",�TORAGE TANK REGULATIONS <br /> FORM A(695) <br />