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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD >t� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> on W <br /> COMPLETE THIS FORM FOR EAC CILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME / — NAME OF OPERATOR <br /> ADDRESS $1 9 S•/��u K iC5 i k S NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME 0 STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ! c�c for` CA <br /> ✓ BOX <br /> TO INDICATE O CORPORATION D INDIVIDUAL PARTNERSHIP O LOCAL AGENCY [7]COUNTY AGENCY 0 STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR 0 ✓ IF INDIAN J#OF TANKS AT SITE E.P.A. I.D.If(optional) <br /> ❑ 3 FARM 0 4 PROCESSOR 5 OTHER ORESERVATION <br /> R 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 /> Luw S , <br /> 14 16L., 2.0 - - /S—b — <br /> NIGHTS: NAME(LAFIRST) PHONE#WITH AREA COOS NIGHTS: NAME(LAST,FIRST) <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS I ✓ boxlvinkate O INDIVIDUAL O LOCALAGENCY STATE-AGENCY <br /> (.20 t% S4L '-.'a.y- V-.Q L-1 CORPORATION 0 PARTNERSHIP I= COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ® . STATE ZIP CODE PHONE#WITH AREA CODE <br /> E e wv n4 ciLtls 3� <br /> III. TANK OWNER INFORMATION-(M UST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> lc-OAC. —{f <br /> MAILING OR STREET ADDRESS ✓ box b indicate INDIVIDUAL 0 LOCAL AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY D 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 F4J 4 - O 3 (e <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box Windicate C] 1 SELF INSURED 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION (_f M 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 cPdcked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. 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 B SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# VA(-(-c �( <br /> 3 ,y 1 1 3 ! U <br /> LOCATIONCODE�OPTIONAL CENSUS TR3ACT# --OPTIONAL S'UPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MU T BE ACCOMPANIED BY AT LEapASSST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SUITE INFORMATION ONLY. <br /> FORM A(12-e1) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> 0 4k / F HOMIA R6 <br />