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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD -,• •� :v� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATI041 ��OF�g1 � 3 <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE 7 -"' •e"e, ro ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OFINFORMATIAa:L,�IC;F f � u,1x.�G1/yR/JTCVI CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE �U�L'VVQY"tl�%C�$ i <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME /G1 �� NAME OF OPTOR eTr / �L�� ,_ r <br /> ADDRESS ( NEARE T CRO_`SSInJSTRREET F`'/ P/ARCCEEL#(OPTIONAL) <br /> I` Kc-�it/Lel�n HUICt4 ( N <br /> CRY NAME STATE ZIP C E E PH E#WITH AREA OD <br /> D I CA a �l� c r _ SIU <br /> ✓BOX O CORPORATION INDMWAL O PARTNERSHIP O LOCAL-AGENCY COUMY-AGENCY' Q S -AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> N o everot UST ap tlic agency.complete the lolbwng:name of stepermsor of division,swim or once 00 operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN IN OF TANKS AT SITE E P.A. I.D.N(opconaq <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAV NAME(UST, N A CQDE DAYS: ( FIRST) PHO N AREA CODE <br /> tiFlJL4 L nr �SP Wc <br /> AIL 3 <br /> NIG S: NAME(LAS".FIRST) PHO N WITH AREA \ NIGH NAME(LAST,FIRST) PHO# N WITH AREA CODE <br /> II. PROPER:liY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME /`61 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS u /�� ✓ oov to ideate Q INDMWAL 0 LOCAL-AGENCY C3 STATE-AGENCY <br /> CORPORATION f]PARTNERSHIP 0 CWMY-AGENCY [::] FEDERAL-AGENCY <br /> CITY NAME n NiN WITH AREA CODET' A <br /> AILSr I� <br /> 7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ,/)(. 0 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORE SS ^ ✓ o loibical, Q INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> Gu r (J CYCORPORATION Q PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME ,S STATE ZIP E P IE� jX E^CODE <br /> �� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) <br /> ✓ambi�cHe 1SELF-INSURED O 2 GUARANTEE O 7 INSURANCE 0 4 SURETYBOND Q s LETIENOFCREDR Q B E%EMPTION O 7 ST RIND <br /> Q ESTATE R1N08 CHIEF FINANCIAL OFFICER LETTER 09 STATE FUNDL CERTIRcATEOF DEPOSIT O 10 LOCAL GOVT.MECHANISM = 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 MILLING: I.❑ It.O III <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> W`ER51 1E(PRINTED R ) TANK OWNERS TITLE � DATE � M`N �C <br /> !(/ <br /> LOCAL <br /> /j AGEE'/NjC'C,)IY/,yU/JSSELI/IyOLlNNLY <br /> COUNTY N JURISDICTION N FACILITY M I� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(8-95) <br />