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• • �60Un <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O 1 N PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION [7] 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 IN RIM PERMIT O 4 AMENDED PERMIT e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 5'r-bL Ii zl— <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Zi 1 r <br /> CITY NAME STATE ZIP SITE PHONE A WITH AREA CODE <br /> 15 vc- CAI/ BOX <br /> TOINDCATE O CORPORATION O INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' (]STATE-AGENCY' =FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public agency,cor iplete the toloWng:name of Supervisor of ftisbn,section,w office which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTORQ _/ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a topuonal/ <br /> RESERVATION <br /> 3 FARN 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> ] <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER IN RMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Gl Df— '�7G.k-TO <br /> MAILING OR STREET ADDRESS ✓ boabiMicaw O INDIV 'AL LOCALAGENCY (]STATE-AGENCY <br /> y %L f�awvw.f U Q CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> Ste-?-0 ter 9yZ407 <br /> 111. TANK OWNER INFOR fiATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> G STT7G�T0 <br /> MAILING OR STREET ADDRESS ✓ heabintlleats O INDIVIDUAL LOCALAGENCY Q STATE-AGENCY <br /> L fL Or�A� O CORPORATION 0 PARTIN HIP COUMYAGENCY (] FEDERAL-AGENCY <br /> CITY NAME SZIP CODE PHONE a WITH AREA CODE <br /> 5:Dc TDn TATE �75ZoZ ft�gJ 93- Sk2 f. <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bat blrAkaN 0 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTEROFCREDIT ED 6 EXEMPTION D %OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECKONE BOX INDICATING WHICHABOVEADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[_-] II. III.0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED)) OWNERS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION>< FACILITY• G,„r— <br /> LOCATION CODE -OPTIONAL CENSUS TRACTa -Q°IIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 1��30 1�S <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE 46iimnoiii ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3931 FORDD)3AA7 <br /> 0 <br /> 0 <br />