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• STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD <br /> • <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o,o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMITc•`I•o^ o <br /> ❑ 5 CHANGE OF INFORMATION <br /> ONE ITEM ❑ T PERMANENTLYY CMSITE <br /> ❑ 2 INTERIM PERMIT ❑ 0 AMENDED PERMIT <br /> ❑ 8 TEMPpggRY SITE CLOSUgE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME <br /> GO � ��0 wO�r NAME OF OPERATOR <br /> ADDRESS <br /> CITY NAME <br /> (> S- NEAREST STREET PARCEL it(OPTIONAL) <br /> GSJf�T STATE ZIP CODE TE PHONE M WITH AREA CODE <br /> ✓BOX CA SP1-! 3S8'—S 3 <br /> TO INDICATE 0 CORPORATION I�INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY <br /> 'M oenerd LIST 4 a Pubrc agency.=Plate the lallmiti:neaeds DISTRICTS O COUNTY-AGENCY' I� STATE-AGENCY' FEDERAL-AGENCY <br /> # upervisord dHision,sedan or oMka Mich Weates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR <br /> ❑ <br /> ✓R INDIAN MOF TANKS AT SITE E.P.A. I.D.#(optional))3 FARM ❑ 4 PROCESSOR 5 OTHRESEVATON <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMAR ER <br /> DAYS: AVE(LAST,FI T) PHONEM WITH AREA COEMERGENCY(LAST, CONTACT PERSON (SECONDARY)-optional <br /> DE OAVS: NAME FlRST) <br /> i ��"`/ w S39 PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) <br /> �� PHONEM WITH AREA CODE NIGHTS: NAME(UST,FIRST) <br /> Lp�•, ��_ 7� � PHONEM WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME <br /> G CARE OF ADDRESS INFORMATION <br /> T <br /> MAILING OR STR ET ADDRESS <br /> moo ' s, s'-�� S7— ✓ �xto ix5rate 0 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> CITU NAME CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> ri J�7' STAT ZIP CODE ONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) — z�U Z�S � 39 <br /> FNAME OF OWNER <br /> r. CARE OF ADDRESS INFORMATION <br /> G OR STREET ADDRESS 7 ✓ box to eM®le WDNIDUA I�LOCAL-AGENCY QSTATE-AGENCY <br /> AME ORPORATION O PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> �T STATFj ZI DEP ONE# ITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UQ ST STORAGE FEE ACCOUNT NUMBER•Call(916)322-99'16/69 if questions arise 3f$-539 <br /> TY(TK) HQ 4 4_ _ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box l#Indcele 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE []4 SURETY BOND (]5 LETTER OF CREDIT <br /> I�B STATE FUND 6CHIEF FINANCIAL OFFICER LETTER []9 STATE FIlNDBCERTIFlCATE OF DEPOSIT 0 18 LOCAL GOVTOMECHAMSM QMPTION OO'ST FUND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS THER <br /> 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: <br /> 1.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MYKNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED 8 SIGNATURE) <br /> TANK OWNER'S TITLE DATE MONTH/OAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION It <br /> FACILITY# �� <br /> S ' /�7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL <br /> b LL SUP'�R1 ISTRIC I CODE -OPTIONAL I ��..}} <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 FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI&TORAGE TANK REGULATIONS <br />