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STATE OF CALIFORNIA y' •--•• t <br /> STATE WATER RESOURCES CONTROL BOARD ; o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A -`� 40 <br /> s•i . o <br /> rp COMPLEETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION L_ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT g TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NE1 NAME OF OPERAIR <br /> ADDRESS ►!`1 RC'-S 1\(.e �� 1 O N S 1 IVC . <br /> (� NEAREST CRYSS STREET PARCEL s(OPTIONAL) <br /> CITY NAME <br /> STATE LP CODE SITE PHONE\0 WITH AREA CODE <br /> ✓ Box <br /> CA �iS33� 2 1 402— 120 5 <br /> TO INDICATE CORPORATION INDIVIDUAL Q PARTNERSHIP U LOCAL-AGENCY <br /> COUNTY AGENCY STATE-AGENCY V FEDEFiALaIGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ^Sx 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN s OF TANKS AT SITE E.P.A. 0.s(aprwnal/ <br /> RESERVATION <br /> 3 FARM h a PROCESSOR Cl S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONEWITH AREA CODE <br /> DAYS: AME(LAST FIRST) <br /> Svc Sbz� qu2-1�-bS (-\RCC �A\ eN\ � N00) 212-, 63 <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME ILAqT,FIRST) WITH AR A c <br /> M(R 1(0'L 402- 12(JS haw I A�t\�-eNLw��� �BUa�2�z- 6> 3 A <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> k��Cv �c Cv t✓\A S <br /> MAILING OR STREET ADDRESS ✓ box Dw4c" INDIVIDUAL a LOCAL-AGENCY STATE-AGENCY <br /> ORPORATION '.^�' PARTNERSHIP S COUNTY-AGE4CY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA COD <br /> Cv\ .q C� q o�0 2—LoU3B• C�l�y ��o-S�v� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> kcocv � CU• 1� isS <br /> MAILING OR STREET ADDRESS ✓ poi ID W14"s <br /> (� LU INDIVIDUAL lJ LOCAL-AGENCY C STATE-AGENCY <br /> ORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL•AGENCY <br /> CCTV NAME r` STATE ZIP COOSPHONE s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HO j4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ Doi u vwWate I SELF INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> S LETTER OF CREDIT 6 EXEMPTION 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.�—.' 11.7- Ill.(� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAM (PRWTEO b SIGNATURE) / APPLICANTS TITLEn 1 DATE NTjAY/VEA*(0 <br /> R <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JU ISDICTION a FACILITY a <br /> I <br /> LOCATION CODE -OPTIONAL [CENSUS TRACT s -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(5.91) FOR0033A-5 <br /> Tv'. ScLci t nry . <br /> STC cokfo Q0... a S')_0�- 0 3 $ <br />