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oo.co, <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMIT [�] 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED. <br /> ONE ITEM 2 INTERIM PERMIT Q 0 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR NAME �G NAM O OPERATOR/ <br /> AD 55 STC ES SCR P CEL#(OPTIO)NAL) I I <br /> CITY NAMESTATE <br /> .-. ! 0 <br /> /� ST CA ZI ODE 517E PHONE q SITH Afp CODE <br /> qq <br /> ✓BOX CORPO TION O INDIVIDUAL O PARTNERSHIP [;--?'LOCAL-AGENCY O COUNTY-AGENCYO STATE-AGENCY' O FEDERAL AGENCY'�I y <br /> TO INDICATE DISTRICTS `` <br /> Hownerol USTBepubTc agency,complete the falbwmg:wme of supenisoral?riaan,sedXn oroNce which operates the UST <br /> TYPE OF BUSINESS 0 I GAS STATION O 2 DISTRIBUTORO ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM O 6 PROCESSOR �5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME( FIRST) PHONE X WITH �C,O E DAV NAME(LIT 51RST) 4{ONE p W=THH AREA CODE <br /> NIGHTS: NAMF�(L ,S FFIIRSi) PHONE#WITH ARE DE NIGHT E(LAST, �O PHONE p ITH AREA CO E <br /> �� ofj 3p _ 6 <br /> Il. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAM P ^ t- CARE OF ADDRESS INFORMATION <br /> I'a 1YJ <br /> MAILNGO TR NDIVIOVAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME S3 5 T ZIgCQy PHONE:p WITH AREA CODE <br /> OD�� <br /> III. TANK OWNER IN 0RMATION-(MUST BE COMPLETED) 77SS QI `] V <br /> NAME9F-QWNER CARE OF ADDRESS INFORMATION <br /> Qli 1�i 04 <br /> MAILING 6RE RESS 2 ✓ bov to rxi ate INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> O d Q CORPORATION PARTNERSHIP [I)COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM ., STji ZIP ODE N PHON W�s,7EAJ=00x9 0 <br /> ano <br /> IV.BOARD OF ALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. S <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to inchoate O 1 SELF-INSURED ED 2 GUARANTEE [::]3INSURANCE [--)4 SURETYBOND E::]5 LETTER OFCREDIT 0 6 EXEMPTION =7 STATEFUND <br /> O 9 STATE FUND&CHIEF FINANCIAL OFFICER LETTER [�:]9 STATE RUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 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 BILUNG: 1.0 11.D III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION It FACILITY# <br /> m 1610 5111- CP <br /> LOCA <br /> -:11ONCODE -OPTIONAL CENSUSTRACTX -OPTIONAL SUPVISOR-DISTRICT CODE <br /> S-O TI NA <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INF RMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />