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0 • <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ±✓e,�h neo <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ?n - <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE m <br /> MARKONCY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED. ITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F ILITY NAME NAME OF OPERATOR <br /> � �� ✓� PA <br /> ADDRESS w NEARES'{.CROSS STREET RCEL I(OPTIONAL) <br /> 29nI . Le9CAts¢. kue UK1oK ITU <br /> C <br /> I NAME STATE LP ODE SITE PHONE X WITH AREA CODE <br /> kc tele CA ��;3� 2+ Fst 3zaa l <br /> .1 BOX 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' 0 STATE-AGENCY' O FEDERAL ENCY' <br /> TO INDICATE TO <br /> #owner al USTls a public egenq,=P1816 IN blbwhig:reme of sepeMsorol d"on,section a aRice which opointa the UST <br /> TYPE OF BUSINESS O r GAS STATION O 2 DISTRIBUTOR <br /> ❑ FN A OF T KS AT E.P.A. I.D.#(W'1an <br /> < PROCESSOR 5 OTHER RESERVATION <br /> 3 FARM � c <br /> TRUST LANDS LnA/TL hW C(s V <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME T. <br /> FIRST) ��P)H�ONIWI—EACOAZ DAYS: NAME(LAST,FIRST) PHONE X WITH AREA COD <br /> A�S"`�•` \\))) '%' PHONE t WITH AREA CO <br /> NIGHTS: NAME(LAST, RST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEI. j �f C }I�) CARE OF ADDRESS INFORMATION <br /> Gt2IC�C+ Ww ✓ • ,✓ <br /> MAILING OR STREET ADDRESS ✓ Eaxb hhdcele 0 INDIVIDUAL LOCALAGENCY 0 STATE FNCY <br /> n� D I I�Yw l�CORPORATION 0 PARTNERSHIP 0{COjU�N Y-AGENCY 0 FEOER ENCY <br /> CITY N�B+�Kk2ec l 'll '/V/� ST/yT ZIP ell ec Ny�WI REA E <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) R ✓/I <br /> NAM O OWN R CARE OF ADDRESS INFORMATION <br /> (tet t& to-S -I) <br /> MAILING OR STREET ADDRESS ✓ boxtonswe OINDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> Pt? 2JCS '3 L .X 'L 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERA+-AGENCY <br /> CITY fll�A1 STAT ZIP ODE PHONE WITH AREA CODE <br /> Ging N L 5124 2�i SIZS—3Z <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b Indicate O 1 SELF-INSURED GUARANTEE 0 3INSURANCE 0#SURETY BOND O 5 LErTEROFCREDrT 0 &EXEMPTION O 7 STATE FUND <br /> D8STATE RINO&CHIEF FINANCIAL OFFICER LETTER O9 STATE RIND&CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM 099 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I orr11 its checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOVED BE USED FOR LEGAL NOTIFICAT10N5 AND BILLING: 1.❑ II.IXI III. <br /> THIS FORM HAS BEEN C PL D UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> T <br /> NAME(PRINTED& E) TA KOWNER'S TI DATE r A27-rl AR <br /> �cvzte� <br /> LOCAL AGENCY USE ONL <br /> COUNTY M JURISDICTION If FACILITY k <br /> ED <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -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 /> OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROJWRAGE TANK REGULATIONS <br /> FORMA(6-95) <br />