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~ STATE OF CALIFORNIA vW <br /> *. <br /> STATE WATER RESOURCES CONTROL BOARD s' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILrrYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 T PERMANENTLY CLOSED SR <br /> ONE ITEM ^I 2 INTERIM PERMIT 6 AMENDED PERMIT Q S TEMPORARY SITE CLOSURE / <br /> 1. FACILITYISITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> C L 6iAIT- <br /> ADDRESS NEAREST CROSS STREET PARCEL$(OPTIONAL) <br /> 60 a - Mfcu_dAJ Ave <br /> CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> ICIMV744A OA - QS�?36 CA <br /> TO INDICATE 0 CORPORATION D INDIVIDUAL Q PARTNERSMP 0 LOCAL-AGENCYQ COUNTY-AGENCY STATEAGENCY (] FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 0 1 GAS STATION u 2 DISTRIBUTOR / <br /> IF INDDIAN A OF TANKS AT SITE E.P.A. L D.#(apffamif) <br /> O 3 FARM A PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) - PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) z a 9-�'� -9a.c/ <br /> T- ao 3� tot s rINITW AREA CODE <br /> NIGHTS: NAME( .FI ST) PHONE#WITHAREACODE NIGHTS: NAME(LAST, IRST) <br /> ,�o - ��3- 9zS� 20 9•�a 3- <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> E CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓WX b1� I] INDIVIDUAL E:] LOCAL-AGENCY Q STATE AGENCY <br /> 660") - A4e,:-4C*-\ '41/1f. IJ CORPORATION Q PARTNERSHIP Q COUNTY.AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE S WITH AREA CODE <br /> ,rsstArvr/«4 bA . �.5 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Eoa bio aw C INOIVIDUAL LOCAL AGENCY Q STATE-AGENCY <br /> C:i;J•CORPORATION = PMTNERSHIP O COUNTY-AGENCY O FEDERAL,AGENCY <br /> CITY NAME STATE ZIP CODE PHONE i WITH AREA CODE <br /> IV, BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if question,arise. <br /> TY(TK) HQ 4 4 D y $ Z 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ EW b'v#iC#A / SELFNSURED O 2 GUARANTEE (] 3 INSURANCE O A SURETY BOND <br /> O 5 LETTER OF CREDT O A EXEMPTION ] m 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.Z II.= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLK:ANTS NAME(PRNTED A SIGNATURE) APPLICANTS TITLEDATE MONTWDAY/YEAR <br /> �llAwd�S� Ui! - 2 9Z <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# h' <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT A -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 /> FORM A(5911 FOR=A3 <br /> C .e� i gra ��� <br />