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14a/ ra/ a <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A <br /> 14 ( <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM F__1 2 INTERIM PERMIT 0 AMENDED PERMIT O 5 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 3 ADDRESS•(MUST BE COMPLETED) <br /> DBAOAFACJLfrV N'&xr& s w NAME OF OPERATOR <br /> ADDRESS 67- /� NEAREST CROSS STREET PMCEL#(OFn0NAU <br /> i2z Goy? - qk'�� <br /> CITY NAME STATE ZIP COpE SITE PHONE#WITH AREA CODE <br /> /'0" T CA <br /> T Nqox <br /> ATE O CORPORATION INDIVIDUAL (]PARTNERSHIP O LOCAL-AGENCY 0 COUNTY AGENCY' O STATE-AGENCY' Q FEDEIUL-AGENCV- <br /> DISTRICTS' <br /> N owner ol UST Is a public agency,complete the loll :name of Supervisor ut division,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN I a OF TANKS AT SITE E.P.A. I.D.i(ophorna) <br /> 3 FARM a PROCESSOR 9P 5 OTHER RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE i WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> SA <br /> MAILING OR STREET A/DD�REES,S�� �—�p� ✓ Oox blydkaN INDIVIDUAL E_�] LOCAL-AGENCY O STATE-AGENCY <br /> Gr(/�cA'.� ST ED CORPORATION (] PARTNERSHIP 0 COUMYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME S�TEA 21P 5 ?JI2— PHONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) G f <br /> NAMEOF OWNER �y..� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boz b indicateINDIVIDUAL O LOCAL AGENCY STATE-AGENCY <br /> 1 ai iA�OY2D ST I�CORPORATION PARTNERSHIP Q COUNTYAGENCY FEDERAL AGENCY <br /> CITY NAME STATE ZIP ODES PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)33222-9669 if questions arise. <br /> TY(TK) HQ F4-F4-1- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm biMicab I SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE (]t SURETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION IN OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I orr--111 its checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <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 S SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY• <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTN)NAL SUPV�ISQR-DISTRICT CODE -OPTIONAL �-�. � g <br /> THISLLFFO-RM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION`- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION OM.Y. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATS <br /> FORMA(3N3) KIN <br /> _ fOReN3I <br /> 4 ,mI <br />