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L 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 n <br /> MARK ONLY F-] 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION T P VAN CLOSED.SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) /(/ <br /> DBA OR FA NAME r� NAME OF OPERA OR Sl <br /> /C <br /> ADDRESSNEARES CROSS STREET PARCEL a(OPTIONAL) <br /> Y ), <br /> CITY NAME b STACE IFy QODE SITE HONE If WITH A <br /> A S U 3CODE <br /> 3 <br /> ✓ BOX O CORPORATION a INDIVIDUAL O PARTNERSHIP O LOCAL AGENCY O COUNTY AGENCY' STATE-AGENCY' = FEDERA--AGENCY' <br /> TO INDICATE DISTRICTS <br /> X ox erof USTB a public agency,mm We the following:name olsWoMsorol aNision,sermon wo6ice MO operates Na UST <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN J#OFTANKSATSITE E.P.A. I.D.M(optional) <br /> RESERVATION <br /> O 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: ME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHO a WITH AREA CODE <br /> a — ,� P 6a d - a S <br /> 11719 <br /> NIGHTS: NAME(LAST,FIR PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> LING 5 EET ADOREp p ✓ bovlouMrate Q INDIVIDUAL O LOCAL-AGENCY 0 STATEAGENCY <br /> aCORPORATION O PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP j)pDE�o ,/ PNE p WIT REA CODE <br /> oil <br /> YS /([ , <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER �V �/ CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORE S,e ✓ boMa.dimle INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> a e l CORPORATION O PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL AGENCY <br /> CITY NAME STATE_ ZIPCQDE�C;�_O PHONE If WITH A EA CODE <br /> 15 ,01, <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBEER`---Call(916))33322-9669 if questions arise. 3 <br /> TY(TK) HQ 4 4- - S 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓W.bodcate I SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND Q 5 LETTEROFCREDIT E-1 6 EXEMPTION [_]T STAiEFUND <br /> 6 STATE FUND d CHIEF FINANCIAL OFFICER LETTER 09 STATE FUND B CERTIFICATE OF DEPOSIT 010 LOCAL GOVT.MECHANISM O 990THEP <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.Re 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 MONTHMAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY�N JURISDICTION It FACILITY p <br /> LOCATION CO K <br /> PTIONAL CENSUS TRACT N -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3-a�1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR"`AIITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI WD STORAGE TANK REGULATIONS <br /> FORM A(6-95) <br /> ,%N/ .Of <br />