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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ��db <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :f - , <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE J' <br /> MARK ONLY F71 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE " <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> A1501 N RESTCROSTR d PARCEL#(OPTIONAL) <br /> I � <br /> ST ZIP CODE ITS p W <br /> ARCCCA � � <br /> ✓BOXI CORPORATION O INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY O COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> H owneraf USTk a Phblb agency.=PWIa me folbwng:name of su#ernwrol dwisbn,section oro#ke which werdea the UST <br /> TYPE OF BUSINESS ICI 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ .1IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> Sd RESERVATION <br /> 0 3 FARM O 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(L, T,FIRST) } ( (� / PHONE#WITH AREA CODE GAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> qAZL <br /> NIGHTS: NAME(LAST,FIRST) N I(•a� /(PHOON WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> N E 1 CARE OF ADDRESS INFORMATION <br /> MAINGOR <br /> ILS �fE�ET ADDFIS .1osb <br /> b ^do �ale INDIVIDUAL D LOCAL-AGENCY O STATE AGENCY <br /> 2i I. 1 'QTCORPORATION EDPARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> C E1r),m STAj):. ZIP RS I AR �OD lWvI <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l/ �A' v— <br /> N OF W75 kfdes CARE OF ADDRESS INFORMATION <br /> MAILING ORSET ADDRESS V' baxtOMCat9 l� INDIVIDUAL 0 LOCAL-AGENCY D STATE-AGENCY <br /> OVV Of Cn CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> ST Zlpf �& P(/- �J / ¢� ODE / <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. (7{ <br /> TY(TK) HQ M44- - � u <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boe to iMiram s SELF-INSURED 2 GUARANTEE 0 3 INSURANCE [::]d SURETYBONO ED 5 LETTEROFCREDTr ED 6 EXEMPTION L-1 T STATEFUND <br /> C:18STATE FUND&CHIEF FINANCIAL OFFICER LETTER C19STATE FUND&CERTIFICATE OF DEPOSIT Oto LOCAL GOVT.MECHANISM 1:199 OTHER <br /> — <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: 1.❑ II.[�] III.❑ <br /> THIS FORM HAS BEEN COMPUTED UN ER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> I <br /> TANK OWNER'S.NAME(PRINTED&SIGNATURE) TANK OWNS DATE MO TWDAV EAR <br /> LOCAL AGENCY USE ONLY <br /> C�OODU INLTYY I�# JURISDICTION# FACILITY# <br /> (11611 1 <br /> LOCATION CODE-OPTIONAL CENSUSTRACT# •OPTIONAL SUPVISOR--�TD ii•OPTIONAL �' ay C� <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 FORM1THE LOCAL AGENCY IMPLEMENTING THE UN�D,JER,(GROORAGE TANKRL�AT`ION� <br /> FORM A(6-95) <br />