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I <br /> I <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A o, <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY ❑ j(q <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE JJ <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPER TOR �. A�tl jsVh <br /> DBA OR FACILITv NAME {�T <br /> /f1 LJIS41LAW r LSh in cj �/G �IJ•, � u, ,l <br /> ADDRESS u'N A 1 ) AREST OR <br /> OSS STREET ARCEL#(OPrN)NAL) <br /> s�SlsoJ /iso. Acin+irf U2n� v iSia <br /> CITY ME STATE ZIP CODE SITE PHONE#WITH ARE CODE <br /> C�If e,7 It ca 19 15 ) ')L yjo t ak 7 1�a � <br /> TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP DISTRICTS ENCY [=1 COUNTY AGENCY I1 STATE-AGENCY Cf FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ❑ ❑ RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR [,g_5 OTHER OR TRUST LANDS I /+ C 0c, t., d llUel OLf <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAVS�:/N,A/ME(LAST,FIRBT) / PHONE#WITH AREA CODE^ DAYS: NAME(LAST,FIRST) <br /> �// �1 �7S✓_/j_ l �.'�✓7 /�j •C1 5)O, dD�� Ihd ITR AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREACODE NIGHTS: NAME(LAST,FIRS 1) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM 77 ECAIAEU� RE$S INF MATIONS,, Com/ `-� O✓1 <br /> C /n , U . iI1MAILING OR ST ET ADDRESS / ndbau IL] INDIVIDUAL O LOCALAGENCY 0 STATE AGENCY <br /> L) gypRATION O PARTNERSHIP 0 COUNTY AGENCY FEDERAL AGENCY <br /> ITV NAME (J / STATE ZIP COD PHONE A WITH AREA CODE <br /> 0C�4)< I `^^ cA 4103- )Cc) A"Dtoga <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CFE <br /> L EhLnDREh S INFORMATION <br /> NM OFISI �fI <br /> SOl ! <br /> 0iMicaa INDIVIDUAL <br /> NGRSVJAD1LXRES\ a<�J 0LOCAL-AGENCY /1 <br /> STAT <br /> Eo-AG�ENCrY <br /> OS 5J FEDERAL <br /> AGENCY PARTNERSHIP �COUNTY-AGENCY <br /> ScTE ZIP OD <br /> C NAME PHONE#WITH AREA CODE <br /> � '3 ) _ W654 3 410j r7Ik 14 lA./ <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 414 - (l o )-513X <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to lntlicale �._] I SELF-INSURED E-1 2 GUARANTEE E:1 3 INSURANCE [__1 4 SURETY BOND <br /> _ 5 LETTEROFCREDIT 6 EXEMPTION L-1 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I orr11l-iss checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.IXI III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSN E(PRINTED&SIGNATURE) APPLICANTSTITLE DATE MONTWDAYNEAR <br /> Sfrror, In-p- <- (�)�s M2/0 L316)119 7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATIONCODE -OPTIONAL ICENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> "71 SU 2LP7 <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 /> PJ,V A(12.91) FILETHIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGETANK REGULATIONS FOR0033A-R6 <br /> 0 <br />