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esoe"ces <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 O t NEW PERMIT 3 RENEWAL PERMIT [�] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE -37 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> /1ux <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPRONAL) <br /> CITY NAME // - STATE ZIP CODE SITE PHONE WITHAREA CODE <br /> 51/_0✓ BOX CIC CA 5� Z-O /' L/L - ,S- <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP ED LOCAL-AGENCY COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION = 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(0PNm l) <br /> 3 FARM 4 PROCESSOR 11 OTHER RESERVATION ? <br /> 0 o 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 /> i�ZyA If,4,h r 1 5-(13- (ff.9 - L11 <br /> NIGHT (LAST,FIRST) I PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> NE 9 WITH AREA ronp <br /> It. PROPERTY OWNER INFORMATION• MUST BE COMPLETED( <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 0 INDIVIDUAL STATE-AGENCY <br /> '(j DL_pq ✓ IMkate � LOCAL-AGENCY <br /> J(a0 CORPORATION PARTNERSHIP =COUNTY-AGENCY I� FEDERAL-AGENCY <br /> CITY NAME ✓(S I STATE ZIP CODE 3-7 S— HONE#WITH AREA CODE <br /> �'3.'�% Y1 - cL - 7)s <br /> III. TANK OWNER INFORMATION--(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> / ATG/ TU641s h� CARE OF ADDRESSINFORMATION <br /> MAILING OR STREE ADDRESS p �,/ ✓ box bilbicate Q INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> 15-f C (,, SC V'/Tj /.�'�.P =CORPORATION PARTNERSHIP 0 COUNTY-AGENCY <br /> D FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 64 f1 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [414] E03 <br /> V. PETROLEUM LIST FINANCI RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ box bindicaleEV 1 SELFINSURED L-j 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT O 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: I.[-1 II.E] III, <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHLDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1207-02 IS <br /> LOCATIONCODE•IOPTIONAL CENSUS TRACT#_OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 2q7 ;-D (0 74f <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B, UNLESSTHIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND NK REGULATIONS <br /> . FOfl00.33AIN <br />