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etboUe • ca <br /> STATE OF CALIFORNIA � ? <br /> STATE WATER RESOURCES CONTROL BOARD i ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ®� a s <br /> e C�linon M•� <br /> C MPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 715 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFOPERATOR <br /> ,Qeco ,C.Ai �rA i � , - Win? <br /> ADDRESS NEARE CROSS STRE T PARCEL#(OPTIONAL) <br /> A17; <br /> .4 L ��3' <br /> CITY NAME STATE ZIP CODEITE PHONE# H AREA COD <br /> D!)Z CA WIT- o/ <br /> v Box <br /> TO INDICATE CORPORATION INDIVIDUAL E__j PARTNERSHIP O LDCAL-AGENCY D COUNTY-AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAS STATION ❑ 2 DISTRIBUTOR ❑ ./ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.4(optimal) <br /> RESERVATION ` <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS �O Sb <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAST.FIRST) <br /> v 637 <br /> NIGHTS: NAME(LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> �Go f v Z 63 '� <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFO MATION <br /> o �OvGTGj Gb . '� O <br /> MAILING OR STREEf ADDRESS p/ ✓ �AblMicate INDIVIDUAL O LOCALAGENCY O STATE AGENCY <br /> jp 'p, O �� Q CORPORATION PARTNERSHIP COUNTY-AGENCY E:; FEDERAL-AGENCY <br /> CI NAME STA ZIP CODE P ONE#WITH AREA CODE <br /> �eT.�5�' 9'c'7o2-6o3b' 3/0 67 - z6o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> M REET4DRS62 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ORPORAT)N -AGENCY -AGENCY CY OST <br /> CI NAME - TA�-TEA ZIP CODE PONE#WITH HEA CODE <br /> �$• G� 702-603 '?�o p7-2(, <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ LX__r�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bbMicate 0 I SELF INSURED I=j 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> O 5 LETTER OFCREDIT =6 EXEMPTION (_J W 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 ADDRESSSHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.X <br /> III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND ORRECT <br /> APPLICANTSNAME(PRINTED A SIGNATURE) APPLICANTSTITLE DATE MONTHIOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTTYY��T# JURISDICTION# F <br /> ACILIT <br /> Y# <br /> -=-7 f /QAC V5 <br /> LOCATION CODE OPTIONAL/ iCENSUS TRACTS -OPTIONAL SUPVISOOR-DISTRICT CODE -OPTIONAL •/ <br /> 36i <br /> 05 <br /> THISFORMMUST BE ACCOMPANIED 9BYYY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A p2 50 FILE THIS FORM wrrRTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS /f <br /> � FORW33A16 <br /> t. � <br />