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STATE OF CALIFORNIAa <br /> STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY �<1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> ONE ITEM 0 2 INTERIM PERMIT Q 6 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> tADD1,RESS <br /> OR FACILITY NAME NAME OF OPERATOR <br /> Dp-LA/joa:S SAM DI-LAvDo <br /> NEAREST CROSS STREET 'I 1�LL_ PARCEL#(OPTIONAL) <br /> Wei€ ST. los-NAME STATE ZIP CODE SITE PHONE a WITH AREA CODELI A/oo CA1752-3� E•USE 7A9�g3142✓BOX ED CORPORATION i�INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' f� FEDERAL-AGENCYTO INDICATE DISTRICTS <br /> O merd UST is a pubicagency,cwnplelethe lolowinirname d superasord dMsbo,Becton orotim which opeales Ne UST <br /> OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR0 RE EIRVNDIAN a OF TANKS AT SITE E.P.A I.D.x(optional) <br /> 0 3 FARM Q d PROCESSOR Q 5 OTHER OR TRUST LANDS 3 GAC-.bol IS144o <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> SPr/n MLAn o 512, Zo^I 9-(03— 7 I TvbD 2-0q (03 �0i6`l6 <br /> NIGHTS: NAME(LAST,FIRST) ONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> n /L 20PHa31 - 5146 'ti 209 9 31- SS8S <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5A-M 4 MAID L A) OtLA M'Da SA-M i- <br /> MAILINGOORSTREETADDRESS ^' ' ✓ boxboccale INDIVIDUAL f�LOCAL-AGENCY O STATE-AGENCY <br /> L-f ZS Q/rKW 106- T/E CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE ONE III AREA CODE <br /> 5 TA G K-Zo n) <br /> If <br /> �S Ir <br /> ZD q 4 3 A z-q`�- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADD ESS INFORMATION <br /> 5A-NI 0 MAlt IL A/ O LihvOD SR/3L <br /> MAILING//O A�R STREET ADDRESS ✓ box fvt' <br /> Ioniate INDIVIDUAL I�LOCAL-AGENCY I� STATE-AGENCY <br /> —1-1 cam- cp,4-W1(_,DE AVGs CORPORATION l`=PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P ONE p WITH AREA CODE <br /> $'7ioGK-T.oAI � �.SZI� Zo1 �T3/-29¢Z <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. <br /> 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boxb indrate SELF-INSURED Q 2 GUARANTEE I1 3 INSURANCE =1 SURETY BOND 0 5 LETTEROFCREDn =&EXEMPTION T STATE FUND <br /> = 8 STATE FIND&CHIEF FINANCIAL OFFICER LETTER O9 STATE RIND&CERTIRCATEOFDEPOSIT O10LOCAL GOVT.MECHANISM = 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.❑ II.1� III.O <br /> T FO HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> KO NE S AME( RINTED&SIGNATURE) TANK OLNItIER-S TITLE DATE NTWDAYNEAR <br /> NLfIc£ LEE I A-fLG/{• I96p7 MAJ&P, <br /> 0 AGE CY USE ONLY <br /> COUNTY It JURISDICTION 8 FACILITY p eO 77W--1, <br /> m IL / � <br /> LOCATION qj CENS <br /> CODE -OPTIONAL US TRACT#•OP71 NAL SUPVISOR R�^COD,E -OPTIONAL �� <br /> a-'Ci 6CT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO MATION ONLY. <br /> FORM q(695) <br /> OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO�TORAGE TANK REGULATIONS <br /> 30 /7 <br />