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• .°°°..�, �o <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD g � R <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A w m� �*e <br /> ��e s,. a <br /> x,.a„e,� <br /> COMPLETE THIS FORM FOR EACH ILITYISITE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY nNAME NAME OF OPERATOR <br /> l'Y� m cl n! Ll rlccv�-G <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> kv CA S 3 0 9 --5- 7 <br /> T NDS(ATE O COflPoRATION (] INDIVIDUAL PARTNERSHIP D IOCALpGENCV D COUNTY+IGENCY D STATE-AGENCY O FEDEML-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION O 2 DISTRIBUTOR 0 RESERVATION #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 3 FARM Q 4 PROCESSOR F�:] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Z vrn a ., u✓, dt.3 - 3/ - 313 <br /> NIGHTS: N (LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Jai l33 33Y 308' <br /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindbale 0 INDIVIDUAL I1 LOCAL-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION- (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkale 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP D COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - (? 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bidicale (] I SELF INSURED 0 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTEROFCREDIT O 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I o II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY Al C0M MV-7l <br /> ay] 1 1 111.21 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a a M I sa3 <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(&91) // FORW33 5 <br />