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�4 '�50Urt0:5 C <br /> STATE OF CALIFORNIA eP ^ <br /> STATE WATER RESOURCES CONTROL BOARD 3 g <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> o <br /> C�(IFOM N,� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM U 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 1,x C'CA a O*ik CGLLA,oA WOCA 0►`1 T nr- <br /> ADDRESS I NEAREST CROSS ST ET PARCEL#(OPTIONAL) <br /> I So i W C�av- -C <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Tac 0 CA 9S-7-010 f Z-c <br /> ✓ BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL [7:1 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY <br /> DISTRICTS FEDERAL-AGENCY <br /> TYPE OF BUSINESS 1 GAS STATION F—] 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR 5< 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) ` <br /> l/QSO19 oke- (7,01) 5 — /, /Z 4Q YiCGt-ste. J i vvy PHONE a WITH AR <br /> F:A CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) (zo C.S� /��—S3Z7 <br /> 'C�y4go►1 /'?Ilk ftoq `95Z-3qS-0 4 Cr.stf►— ivv► <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMER//�� N^ II CARE OF ADDRESS INFORMATION <br /> rr7a1 A c lrA Mc berSo," (.J�o�S Oil --C-,?C- <br /> MAILING OR STREET ADDRESS ✓ box IDindicate <br /> /� / Wes <br /> INDIVIDUAL � LOCAL-AGENCY � STATE-AGENCY <br /> IO(O Fr-OLn W <br /> k es C i t-j C'' CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S4 oafo(^ CX <br /> tP s- yii <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> i pI / <br /> __�a € !t ar c/ pL'irsoH I/W/�oo/S ©1( Z►IG <br /> MAILING OR STREET ADDRESS ✓ box to indicate <br /> IO` j 1 /+ p INDIVIDUAL 0LOCAL-AGENCY [�STATE-AGENCY <br /> L! Fr c,Pi k L—)es 1 Ci v-c1 O CORPORATION PARTNERSHIP E:1 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> S +-m C-A 9.sZo(o (zcli) <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ [4T41-nZ. yl 5 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> O 5 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. II. II. <br /> THIS FORM HAS BEEN COMPLET NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> PPLICANT'S NAME(PRINTED&SIGNATU ) -._.�l.c APPLJ yT� -.. i DA /��E <br /> Ly-oytvj <br /> 0)v <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL ICENSUS TRACT# -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(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br />