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• STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD oM1 a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR/FACILITY NAME ��//��//�� NAME OF OPERATOR <br /> // LSI <br /> ADDRESS -/( ("eNEAREST CROSS STREET _ �.4 PARCEL 9(OPTIONAL) <br /> CITY NAME-S '/`J1- STATECA ZIp C0DE 95a FJ•LfJ_YLVy SITE PHONE WITH AREA COD <br /> TO INDICATE - CORPORATION D INDIVIDUAL l� PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' O STATE-AGENCY O FEDERAL- ENCY' <br /> DISTRICTS <br /> H <br /> mar d USTu apublicagerq.Mplelethe Tollowing IBme d slpephsoroi dmSion,sw.tion oroKwwhich epemles the UST <br /> TYPEOFBUSINESS O 1 GASSTATION ❑ 2 DISTRIBUTOR ✓ TA� <br /> IFINDIAN NOFAT SITE E.P.A. I.D.#Np#onap <br /> ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHO E N WITH AREACODE 4 DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CFE E <br /> 0�0 <br /> NI TS: NAME T.FIRST) a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA COE E <br /> /— <br /> II. PROPERTY OW ER INFORMATION-(MUST BE COMPLETED) <br /> NAME CAR OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bos le Q INDIVIDUAL =LOCAL-AGENCY Q STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP =COUNTY-AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> ANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME FOWNER CAR FA RESSINFORMATION <br /> G -W,Q e <br /> MAILING OR STR//E,'ET''ADDRES ✓ box to ugiple Q INDIVIDUAL LOCA.AGENCY STATE-A(ENCY <br /> I VV CORPORATION [--] PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITU NAM 1 TE ZIP CODE PHONE N WITH AREA CODE <br /> Ukf3 (po � <br /> I OUALIZA ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO F4 [4-1-0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED Q 2 GUARANTEE E:1 3 INSURANCE Q 4 SURETYBOND 0 5 LETrEROFCREDIT I�]6 EXEMPTION [::]7 STATEFUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIRCATEOFDEPDSIT l= 10 LOCAL GOVT.MECHANISM ED N 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 BILLING: I.X II.❑ III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> LOCAL AGENCY USE ONLY GJjD a31 65 1 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUI!aN - PTIONAL SUPVISOR-TRIC©D --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 /> FORM A(6-95) OWNER MUST FILE THIS FORM4k THE LOCAL AGENCY IMPLEMENTING THE UNDERGROt�ORAGE TANK REGULATIONS <br /> L_ <br /> a�- 9 /<yg <br />