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!,•goVA 'J C <br /> 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 /> MARK ONLY NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SjTF- <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> r)RA OR FACILITY NAMEf NAME OF OPERATOR <br /> _ K S GAS t 6'e0646.e LPOOod Y. 07 AI fSWA)eA0 CH0tfHAk1 <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> dolt, CH�21"E2 U'q/ <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> .SToCKi o� CA y5 2 ��v Lo9) y H7-0305 <br /> ✓ BOX LOCAL•AGENCY <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP 0 DISTRICTS' COUNTY-AGENCY' 0STATE-AGENCY FEDERAL-AGENCY' <br /> 11 owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS F-1 1 GAS STATION [:] 2 DISTRIBUTOR ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER 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#WITH AREA CODE <br /> OrAll7AA) , KNAL_ CoA) (209) 9 2-107110 6,91,4&V -H7l1NAA✓ (2C <br /> NIGHTS NAME(LAST,FIRST) PHONE#WkAACACIDWV NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1-?, <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSw/){� ✓box b indicate INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> tic CORPORATION [}Z PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME LJ r` STATE ZIP CODE PHONE#WITH AREA CODE <br /> «Tn�/ <br /> C ,4 _'S 63 o5 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER �jplcit<� `�DCARE OF ADDRESS INFORMATION <br /> v ,li r <br /> MAILING OR STREET ADDRESS <br /> �q ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY ] STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - 63 �p " <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate [_1 1 SELF-INSURED E::]2 GUARANTEE 0 3 INSURANCE 0 4 SURETYBOND <br /> E:J 5 LETTEROFCREDIT 6 EXEMPTION 99 OTHER :d <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. 11.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNERS TITLE DATE MONTH/DAY/YEAR <br /> j. <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m1-54-141- FTq <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OP77ONAL <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 REGULATHM <br /> FORM A(3193) FOR0033A-i7 <br />