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L - STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT z 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 0 a TEMPORARY SITE CLOSURE / <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> qRA OR FACILITY NAM NAME Of <br /> C0� /_ 6 b7E vl� � e �k'> c r /� mf)i�i <br /> ADDRESS / �C NEAREST CROSS STREEj� ^� PMCEL II(OPfIDNAy <br /> CITY NAME STATE ZIP #WITH CODE SITE PHONE H AREA CODE <br /> Ca ,. 5-�30?0 <br /> TOIN BOX O CORPORATION O INDIVIDUAL PARTNERSHIP O LOCAL-AGENCY COUNTYAGENCY' STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> •N owner d UST Is a public agency.Oowlde the following:name of Supervisor of dNH.bn,section,or OffWhich Operates the UST <br /> TYPE OF BUSINESS ®, 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.A(ap#Onag <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER 1, OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS NAME(LAST,FIRST) PONE#WITH AREA CODE NIGHTS: NAME(LAST PHONEt WITH AREACODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ) ^�.,Y / -J.� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS / ^/ .1 box bindbate a] INDIVIDUAL = LOCAL-AGENCY � STATEAGENCY <br /> OG _� u <br /> 7 pd— �' " =cORPORAnON E-1 PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> iCITY NAME ` 1pr ( /) _J ^'��- � STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER _/i/// _�19, CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �f �^�y n 1 ✓ hox blMrau O INDIVIDUAL E:] LOCAL (]STATE-AGENCY <br /> Iq/'t, PjeJ 7 J J'� 7 Q CORPORATION 5Z PARTNERSHIP = COUNTY AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE _ PHONE A WITH A/RE�A CO <br /> L - (` i W � � 'I <br /> IV.BOARD OF EQUALIZATION UST S�TORAAGGGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HO F4-14--] I�'Tl� j I 1-I <br /> bd-7 /l <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Dox bindbale 0 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE O 4 RETY BOND <br /> 0 5 LETTER OF CREDIT O 6 EXEMPTION O 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: I.® U.O III-0 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNE R'S NAM E RINTED d S IGNEDI .r=-- OWNER'S TITLE DATE f}ONITWQAYNEAR <br /> -J Urfa;: <br /> LOCAL AGENCY USE ONLY y <br /> COUNTY It JURISDICTION# FACILITY# <br /> LOCATION COO$-OPTIONAL CENSUS TRACTA -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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3193) FOROSIM-117 <br />