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STATE OF CALIFORNIA 'e�.o c+r <br /> STATE WATER RESOURCES CONTROL BOARD u d� m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :r - <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ro ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION T PERMANENTLY CL .SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMEv� GV T 1� ' NAME OF OPERATOR <br /> ADDRESS 14 At&z U�°Crfa4a-�e.-�'�o NYRE TCROBS STREET PARCEL#(OPTIONAL) <br /> CITY NAME n - STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Lp4�( CA — _ 7 D <br /> ✓BOX (]CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY-AGENCY' STATE AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> X uenerof UST B a publt agent,=plate Ua following name d supervisor d dhrisun,section oro8ke xiliN operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 ✓IF INDIAN #OF TANKS AT SITE E.P.A I.D.#(optianel) <br /> Q 3 FARM 0 4 PROCESSOR �YOTHER ORRTRUSTVLANDS <br /> C or>! 3�313 6 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME-(LAST,FIRST) PMO E#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> x, 777 A l ZG / �� a / �7 g6? D <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> `d% 3861" <br /> 6 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> flth7l '/ZS7 Al <br /> MAILING,OR STREETT ADDRESS ✓ box to iidsale &RINDNIDUAL EDLOM-AGENCYEJSTATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ` STAj� ZI DE PHONE#WITH AREA CO <br /> 4—a' G/ 7 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa to Indicate O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCO NT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 /`7A <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa 10 indicate 1 SELF-INSURED EEI 2 GUARANTEE 0 3 INSURANCE O 4 SURETYBOND Garuirra OF CREDIT = 8 EXEMPTION 17 STATE FUND <br /> O8 STATE RIND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0990THEP <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.❑ II. III.❑ <br /> THIS FOAM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TMOWNNER'S NAM@(PRINTED&SIGNATURE) _ TANK OWNERS TIRE DATE M0NEAR <br /> 10 <br /> LOCAL AGENCY USE rU[®SE ONLY � �z1 <br /> COUNTY# JURISDICTION# FACILITY#j96 7M. <br /> m 15-16171 Apa <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 /> FORMA("S) OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGR(eSTORAGE TANK REGULATIONS <br />