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% Ifn <br /> s <br /> �4 <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD A <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACHFACILrTY/SITE <br /> MARK ONLY D 1 NEW PERMIT I] 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE REM Q 2 INTERIM PERMIT L__1 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE �( <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB FgqGcILITV E NAM OF OPERATOR <br /> 4 �r a Bch ` ry Y1 pit' <br /> ADDRESS NEAREST CROSS REET PARCEL#(OPTIONAL) <br /> 11 �1 M or Z <br /> DICE 1 STATE ZIP CODE ITE P NE s WITH AREA CODE <br /> /lf OC 1 y( CA 9 ; C) <br /> ✓ �A t LEI CORPORATION 1 INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY [�COUNTYAGENCY' Q STATE-AGENCY' Cl FEDERALAGENCY' <br /> TO INDICATE / - DISTRICTS' <br /> N inner W UST is a public agency,complete the following:name of Supervisor of division,section,or onice which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR / <br /> IF INDIIAN ON A OF TANKS AT SITE E.P.A. I.D.A(optional) <br /> Q 3 FARM 4 PROCESSOR 6 OTHER OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY : NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> .t t 3I��DOO <br /> TS: NAMEjLAST, IRS PHONE0WITHAREACODE NIGHT5: NAME(LAST.FIRST PHONES WITH AREA CODE <br /> A+ <br /> It. t ae 31 —�I7 <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAI,,;. CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREET ADDRESS ✓boa binN'cafe INDIVNIUAL = LOCAL-AGENCY D STATE-AGENCY <br /> 1 7 1 W CORPORATION = PARTNERSHIP = COUNTY-AGENCY ='"FEDERALAGENCY <br /> CITY(=E STATE ZIP CODE -HONE N WITH AREA CODE <br /> ►�- o �I d <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NA OF OWNS CARE OF ADDRESS INFORMATION <br /> T r <br /> MAILINGOR STREET ADDRESS �'�/rblMaaie = INDIVIDUAL EDLOCAL-AGENCY =1 STATE AGENCY <br /> 3 p1 � I U+ CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> Or NAMESTATE ZIP CODE PHONES WITH AREA CODE <br /> oai� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCI L RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa biMkate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT E:l 6 EXEMPTION O 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: LE H.El III.INK <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED SIGNED) OWNER'S TITLE DATE MONTH/DAV/VEAR <br /> /'f - _ Wil. . / I /C,� - . 98 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -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 SrTE INFORMATION ONLY. <br /> FORM A(3193) OWNER MUST FILE THIS FOFW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRII STORAGE TANK REGULATIONS <br /> FOR003AA7 <br />