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STATE OF CALIFORNIA • .°je.���e <br /> ^ oti <br /> STATE WATER RESOURCES CONTROL BOARD u dam, m°a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A >m _ <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE �e.,,,e;,.,�- <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> CXW T O V11 Pro S M <br /> ADDRESS <br /> ;IA�f�-7 /��S / / ISP NEARES�'CR;S SSTREET�j ^ PAnRCELt(OPTIONAL) <br /> CITY NA✓ � ✓� T (.�A SVTVDDAIICEA ZIP <br /> —L CODE <br /> 5 I�IVp� �I'L) SI L�Q #Wcj 56 cGZ52o <br /> ✓ BOX CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP D LOCAL-AGENCY DCOUNTY-AGENCY' OSTATE-AGENCY' 0 FEDERAL-AGENCY- <br /> TO INDICATE DISTRICTS <br /> 9 owner of UST is a public agency,complete the folbwing:name ol supeMsor of Qrvwbn,swim or office which opeates the UST <br /> TYPE OF BUSINESS m i GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN MOF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q A PROCESSOR Q 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST)' P ON p WITH AREA CODE DA NAME(LAST,FIS Py6Nr N TH AREA CODE,,... <br /> NIGHTS: <br /> NAME(LAST ST) HON WITH AREA CODE NItTzNAME(LAST,FI T) HO #2H3R1E-A CODE <br /> SOO Z31 - 062 ,rvr\ 6 <br /> Z3 <br /> II. PROPERTY OWNER INFORM ION-(MUST BE COMPLETED) <br /> NAME. � GI / Mf <br /> ICARE OFA DRESS INFORMA <br /> MAILING `STREET ADDRESS ] (� ✓ boabirdrale I� INDIVIDUAL E::] LocAAL-AGENCY Q STATE-AGENCY <br /> P,0 x 606 CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY,LJAMaN_ LtiiV✓�O r-� S�A ZIPC D4S83 FJO�2 WI AREA COOS 040 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) C 8 Z <br /> NAME OF OWNER ^ CARE OFADDRESS <br /> INFO ATION L <br /> r6r ro (yl Al C h14 1 <br /> f/Y�L {S <br /> MAILINGOR STREET ADDREBS ✓ to n0icote OINDMDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> U.- ( x �D CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P NEN TH AREA CODE <br /> Su , cA 6711`5-0 -3 2 z-gooZ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- 0 3 / <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to ir6caam 1 SELF-INSUPED 0 2 GUARANTEE 0 3INSURANCE [:14 SURETYBOND 0 5 LETTEROFCREDIT 0 0 EXEMPTION 0 7 STATEFUND <br /> 0 STATE FUND d CHIEF FlNANCIAL OFFICER LETTER 0 9 STATE FUND d CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 0 0 OTHER <br /> A. 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.ElIII.N9 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY7 PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> NAME(PRINTED&SIGNATOR FANK-eV7NeIP6 TITLE DATE MON AV/YEAR <br /> LOCAL AGENCY USE ON <br /> COUNT/# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 FORK THE LOCAL AGENCY IMPLEMENTING THE UNDERGROJWFIAGE TANK REGULATIONS <br /> FORMA(6-95) <br />