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STATE OF CkL1FORNIA hr .....• c <br /> STATE WATER RESOURCES CONTROL BOARD LL <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A - <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> r MARK ONLY Q 1 NEW PERMIT 3 RENEWAL PERMIT ❑ ` CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMrr Q 4 AMENDED PERMIT Q B TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FPCILfY NAME NAME OF OPERATOR <br /> f AO RES5 NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Ivo S Gip � <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Z":%.>/ Ca Zy D <br /> ✓sox p CORPORATION Q INDIVIDUAL © PARI IERSHIP p LOCAL-AGE14CY ©COUNTY4CENCY• p STATE-AGEICY- Q FEDERAL-AGENCY• <br /> TO INDICATE DISTRICTS I <br /> '"owner of UST's a public agency,complete the fatlawng:mum d supervisor o1 dMlsimh,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓1F TE INDIAN #OF TANKS AT SIE.P.A. 1,D.#(CptionaO <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> OAY : E( ,FIRST) PHO #WITH AREA CODE DAYS: NA I-(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS. NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS,. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME y CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS `� °° © INOMOUAL Q LD AL-AGENCY Q STATE-AGENCY <br /> Z/ZD 'q • Gpd - JQ�� ©CORPORATION Q PARTNERSHIP Q COMNTYAGENCY © FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE# LTH AREA CODE <br /> ,3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME,OF OVVNER CARE OP ADDRESS INFORMATION <br /> .fie/^ ��i Jr� €E <br /> MAILING OR STREET ADDRESS ✓ bM'10lyd= p INDMOUAL Q LOCAL-AGENCY �] STATE-AGENCY <br /> L7 F Q CORPORATION Q PARTNERSHIP Q CDUNTY-AGENCY [� FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE ONEWITH AREA CODE <br /> v - <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-ICall(916)322-9669 if ques#ians arise. <br /> TY M HQ, -4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETE=D)—IDENTIFY THE METHOD(S) USED <br /> ✓boa fo Ind Q I SELF4NSURED Q 2 GUARANTEE p 3 INSURANCE 0 4 SURETYaONO Q 5 LETTER OF CREDIT []6 EXEMPTION p 7$TATE FUND <br /> p 8 STATE FUND d CHIEF RNNX1AL OFFICER LETTER Q 9 STATE FUND&CERTIRCATE.OF OEPOs1T © 10 LOCAL covT.MEcHANIsm = 99 OTHER <br /> I <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. 11. 111.O <br /> THIS FORM•I-fAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND 70 774E BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> TANK OWNER'S NAME{PRINTED Q SIGNATURE TANK OWNER'S TITLE DATE MONTHiDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 7 a o 5 <br /> LOCATION CODE -OP77ONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL <br /> OZ- " <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B.UNLESS THIS IS A CHANGE OF SITE 11FORIOIATION ONLY, <br /> OWNER MUST FILE THIS FOTHE LOCAL AGENCY IMPLEMENTING THE UNDERGR -STORAGE TANK"REGULAT10NS <br /> FORM A(&95) <br />