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lf • f. 'L60J- - <br /> t# STATE OF CAUPDR14A �a <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 'ani, ', <br /> 9 . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'��•aa"'' <br /> MARK ONLY Q )/NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION [ 7 PERMANENTLY CLOSE <br /> ONE REM LY2 INTERIM PERMIT Q 4 AMENDED PERMIT Ij & TEMPORARY SITE CLOSURE 40 7i <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAOR FACILI NAME NAME OF OPERATOR moi/ <br /> VI 3yj LA.ryslif-'% <br /> ADDRESS INEARESTCRR$S STREET PARCEL*(OPTIONAL) <br /> Z <br /> CITU NAME ST Z� r3 SITE PHONE a WITH AREA COD) <br /> Ca <br /> J 2�-�i5 —g'r <br /> TOINgCXff 71 CORPORAWN INDIVIDUAL I� PARTNERSHIP O LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public age ,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN I#OF TAeN0 ATSITEE.P.A. I.0.*f4odonag <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS v <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> [DAYS;:TNAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE <br /> S: NAME(LAST,FIRST) PHONE*WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NA9; CARE OF ADDRESS INFORMATION <br /> &/s LA wSzr! 0�k I; <br /> MAILING OR STREET ADDRESS ✓box WrldicaN INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAM av STATE ZIP CODE `` PHONE*WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �Cr-m'ei - <br /> MAILINGORSTREETADDRESS ✓ box birdbale 0INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNEASHP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boxbirdbate O 1 SELF-INSURED O 2 GUARANTEE L-1 3 INSURANCE 0 4 SURETY BOND <br /> f7 5 LETTER OF CREDT a EXEMPTION 0 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 the ked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D II. It. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION 0 FACILITY# 71 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* .OPTIONAL SUPVISOR-DI <br /> zQ yo <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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(Y93) 0 FOfl9N3A H7 <br />