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• ',60Ua :9 CO <br /> STATE OF CALIFORNIA °"^ ^ <br /> O STATE WATER RESOURCES CONTROL BOARD ;�P m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �� �e <br /> � > o <br /> C�(,eOe N^� <br /> COMPLETE THIS FORM F EAC CIL Y/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CH GE OF INFORMATION 7 PERMANENTLY C <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILLITYNAME NAME OF OPERATOR <br /> can a� 0( �Oa y <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> IxOn <br /> CITY NAME BTATEZIP CODE SITE PHONE#WITH AREA CODE <br /> S CA 6 oy- 9,P 3- yo <br /> TOINDIICCATE ORPORATION ] INDIVIDUAL ] PARTNERSHIP O LOCAL-AGENCY I] COUNTY-AGENCY ] STATE-AGENCY ] FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(optimal) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR OTHER OR TRUST LANDS <br /> E Y CON ERSON (PRIMARY) EMERGENCY CONTACT PERSON ISECONDARY)•optional <br /> DAYS: NAME(L IRST) HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ISR j C h?P u9-SYb-a Y '— <br /> NIGHTS: NAM LAST.FIRST) _5_C40NE#WITH AREA COOL NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME / CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓'Ox"III""e ] INDIVIDUALE_] LOCALAGENCY ] STATE-AGENCY <br /> a4 D we r CORPORATION O PARTNERSHIP ]COUNrYAGENCY I] FEDERAL AGENCY <br /> CIN NAME Sok STS ZIP CODE PHONE#WITH AREA CODE <br /> & <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MA_ <br /> ILING ORSTREETADDRESS• ✓ la+m indicate ] INDIVIDUAL ] LOCAL AGENCY ] STATE-AGENCY <br /> [L]CORPORATION = PARTNERSHIP ] COUNTY-AGENCY ] FEDERAL-AGENCYCITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> e <br /> IV. BOARD OF EOUA,5=1L!1TY <br /> CCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 �V. PETROLEUM UST FINAN -(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bo+roindicate 1 SELF INSURED ]2 GUARANTEE <br /> 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION ] 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 c cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# J)MIM-7-$ <br /> LOCATIONCODEOPTIONAL (CENSUS TgACT# -OPTIONAL SUPVISOR-DISTRICTCODE OPTIONAL <br /> © -3 ft 3d-3 00 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORMS,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS/ <br /> FOflDO66A-R6 <br />