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y .�. <br /> STATE OF CALIFORNIA ��' `i <br /> D <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A �� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `'��.aa+`- <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT F-] 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME NAME <br /> NAME OF OPERATOR <br /> ADDRESSz� N EAf1ESTCFPSS STREET PARCEL 0(OPTIONAL) <br /> T <br /> CITY NAME STATE 0 CODE ITE PHONE a WITH AREA CODE <br /> Lvn^ ca 7c> -56;k-0 aS <br /> TOINDI ATE E::]CORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY AGENCY' O STATE AGENCY' O FEDEIULAGENCY' <br /> DISTRICTS' <br /> 'N owner of UST Is a public agenry,conplete the foRmAng:name of Supemisor of ONbbn.section,w office which operates the UST <br /> TYPE OF BUSINESS = 1 GAS STATION Q 2 DISTRIBUTORRESEIF INDIAN RVATION aOF TANKS ATSITE E.P.A. I.D.e(ppf/wW) <br /> 0 3 FARM 0 4 PROCESSOR O 6 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(UST,FIR �] <br /> ST) PHONE a WITH AREA OODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> /2�GF.,& Z�I _4f - <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> Tai � 41 <br /> - <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Z <br /> f <br /> MAILING OR STREET ADDRESS ✓boa b kielcate O INDIVIDUAL 0 LOCAL-AGENCY Q STATE AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTYAGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE# A AREA CODE <br /> E a a <br /> III. TANK OWNER INFORMAT ON-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> C. de. S� TL- <br /> MAILING ORSTREET ADDRESS / ✓ bubldcate = INDIVIDUAL 0 LOCAL-AGENCY O STATE AGENCY <br /> !j f / CORPORATION = PARTNERSHIP � COUNTY Q FEDERAAGENCY <br /> c��� STATE ZIP CODE PHP 2.0v7( HjAREACODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9-9666699 if questions arise.J1 G "�v <br /> TY(Ti HO F41_4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bm NYdkYa D I SELF-INSURED Q 2 GUARANTEE 0 3 INSURANCE O A SURETY BOND <br /> 1=1 5 LETTER OF CREDIT Q a EXEMPTION Q W 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED d SIGNED) OWNERSTRLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION• FACILITY <br /> m 3 7 6/.y/s'6 <br /> LOCATION CODE -OPTIONAL CENSUSS -OPTIONAL SUPVISOR.DISTRICT CODE -OPTIONAL <br /> o 7,gTRACTr?0 412,011e- <br /> THIS <br /> 1d 1LTHIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IMFr0RmAT=ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONB <br /> FORM A(3133) Flx011111Mf/ <br />