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STATE OF CALIFORNIA J <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE to <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION a ] PERMANENTLY CLOSED.SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 8 TEMPORARY SITE CLOSURE Pq <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADNEAREST CROSS STREET PARCELt(OPTIONAL) <br /> DRESS <br /> PlC7' Gt►'0 i0✓�- <br /> CITY NAME STATE ZIP CODE -D SITE PHONE It WITH AREA CODE <br /> !�' S� _4 <br /> ✓ BOX ED CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE T DISTRICTS <br /> ' <br /> 11a .rof USTisapu agvW.=pleN the following:twos d su rAWrddm;vme,MxtiWtXoftwhidi t edmtha UST <br /> TYPE OF BUSINESS 1 GAS STATION E=) 2 DISTRIBUTOR O ✓IF INDIAN A OF TANKS AT SITE E.P.A. L D.k(optional) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P ONE t WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE t WITH AREA CO E NIGHTS: NAME(LAST,FIRST) PHONE N WITH ARE. '.ODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bosW Mrata (]INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> Old Gd0 a CORPORATION Q PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGBICY <br /> CITY NAME STATE ZIP CODE PHONE Y WITH AREA CODE <br /> GvL7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWN R CARE OF ADDRESS INFORMATION <br /> ;1 /e_�119I <br /> MAILING OR STREET ADDRESS ✓ box m YMl:ale Q INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> QO E - GQQl AI =CORPORATION PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY N'AMyE- STATE ZIP CODE PHONE t WITH AREA CODE <br /> f�� C4 1g <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 44- -� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boamY�a 1 SELF-INSURED O 2 GUARANTEE =3INSURANCE O 4 SURETY BOND =5 LETTER OF CREDIT O 6 EXEMPTION (]T STATE FUND <br /> � e STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT O10 LOCAL GOVT.MECHANISM O98OTHER <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.Q IL[:] III.O <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'S TITLE DATE MONTHIDAWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION M FACILITY p <br /> 0 78 <br /> LOCATION CODE -OPTIONAL CENSUS TTR-±AC�TN -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> Z3.�J <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 /> OWN LR MUST FILE THIS FORK i THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULP TIONS <br /> FORM A(6-95) 1j <br />