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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> I� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T PERMANENTLY LOSED 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 1 4 0 NAME OF OPERATOR <br /> ADDRESS i.i N REST(G RO ISSSTREET PARCEL#(OPTIONAL) <br /> a � r 4 Gv7 <br /> CITY NAME STATE ZIP ODE SITE PHONE It WITH AREA CODE <br /> G <br /> 0ff CA o5 <br /> ✓ BOX O CORPORATION INDIVIDUAL O PARTNERSHIP D LOCAL-AGENCY D COUNTY-AGENCY' C::] STATE-AGENCY' O FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #ownerof USTbapubreagenq,=Pm teNef09awhg:IWneofsupeMwrddi Kmn,#edionoro#NewhEhopeletOthe UST <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> AN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> ❑ 3 FARM ❑ 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH REA CODE DAYS: NAME(LAST,FIRST) P ONE#WITH AREA CODE <br /> > �r fa¢ a. Vi' <br /> NIGHTS: NAME(LAST,FIRST) / PHONE#WITH EA CODE NIGHTS: NAME(LAST,QRST) Q.11H AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD RESS ✓ box to nCxale INDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> D CORPORATION Q PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#W TH AREA CODE <br /> 1 L)F,/ {{ -nom• G/T ao *71 -It36, ;I- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxtondirate Q INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP O 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 /> ✓box to iMkala 1 SELF-INSURED =2 GUARANTEE =31NSUR.ANCE =4 SURETY BOND = 5 LET TER OF CREDIT =8 EXEMPTION [-17 STATEFUND <br /> S STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL 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: 1.❑ II. III'❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY ? <br /> COUNTY# JURISDICTION# -"-"F'AEttt <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVIS,OIR-�DISTRICT CODE -OPTIONAL <br /> CY'R( 0 <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 u <br /> THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO' TORAGE TANK REGULATIONS p <br /> FORMA(B-95) s ._aq-yg <br />