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• 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 - <br /> In- <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT <br /> ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY <br /> Mt <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT <br /> ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> M <br /> IL NAME <br /> 0 N 4, NAME OF OPERATOR <br /> S Pr v <br /> p NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> tt// I `sem " Zl9� GHSITE PHONE#WITH AREA CODE <br /> Q CORPORATION O INDIVIDUALTE �(PARTNERSHIP 0 LOCA4AGENCY D COUNN-AGENCY'DISTRICTS O STATE-AGENCY' O FEDERAL-AGENCY' <br /> UST is a pub4c agenry,mmplele the lolbwing:nameofs,gernsowltlhisionsedan oroHice which operates the UST <br /> SINESS ❑ I GAS STATION O 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> ❑ 3 FARM ❑ 4 PROCESSOR N 5 OTHERO RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> RM <br /> : NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> / DAYS: NAME(LAST,FIRST) PHONE-WITH AREA CODE <br /> N d 1� /- /O GBS 4E: 'e <br /> TS: NAME(L45T,FI T) PHONE#WITH AREA CODE �� l e7 a <br /> NIGHTS: NAM (LAST,FIRST) PHONE#WITH Aq EA CODE <br /> C. r Q „r o.)9 yo -� zg8-v6- <br /> # _ <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) 7 <br /> tNAME / CARE OF ADDRESS INFORMATION <br /> ADDRESS NCA ✓ box to 6 ate Q INDIVIDUAL QLOCAL-AGENCY STATE-AGENCY c {✓ CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> C/} Sao �( <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> [NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> c T AILING OR STREET ADDRESS <br /> ' ✓ box CORPORATI INDIVIOUAL O LOCAL-AGENCY O STATE-AGENCY <br /> TY NAME ` CORPORATION Q PARTNERSHIP O COUNTY-AGENCY Q FEDERAL AGENCY <br /> STATE 21P CODE PHONE#WITH AREA CODE <br /> Grp 96©0$ o $ no <br /> IV.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 METHODS) USE <br /> ✓box to inacale l= I SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE = 4 SURETYBOND r AT <br /> = &STATE RIND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT L �OtO LOCDALTGOV,T�MECHANSMTIOO L_J TE FUND <br /> 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: <br /> I.❑ 11.29 III.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGN E) <br /> �I yy TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> o#Ja/L �c G o vl /�,"caatI7'' Oc7c3uY Z7� I4R7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# <br /> FACILITY# 5i7 <br /> LOCATION COOE -OPTIONAL CENSUS TRACTN -OPTIONAL <br /> SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED;777 <br /> EAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A IS 95) OWNER MUST FILE THIS FORM*THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO&TORAGE TANK REGULATIONS <br />