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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A t <br /> COMPLETE THIS FORM FOR EACH FACILITY/srm id <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT n CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT — 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME QU F OPERATOR MPS 115 ^ <br /> C. <br />` <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL} <br /> 2-,Z 'l fz�4.(Y�n, t. ��, �� 14-1 - 214-'- �3 <br />`- CITY NAME STATE 71P_C� _ , SITE PHONE#WITH AREA C. CI O�S <br /> STS Ic�� CA! C•I �TifC`�r <br /> ✓ BOX MR-CORPORATION NOWMAL ©PARTNERSHIP []LOCAL-AGENCY r COLINTY•AGENCY, CD STATE-Army' Q FEDERAL-AGENCY' <br /> TO INDICATE .p DISTRICTS <br /> #mwmr d UST is a pAft a9enc7= the tokwirtg rams d supervanr CO Gmsiott.section ordfiee which operates the LIST <br /> TYPE OF BUSINESS t GAS STATION ❑ 2 DISTRIBUTOR 0 RESv,IF INDIAN ERVATION *OF TANKS AT SITE E P.A I.D.r(opticng!) <br /> Q 3 FARM Q 4 PROCESSOR 0 5OTHER OR TRUST LANDS 2 coo <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)--option( <br /> DAY& NAM�E� . <br /> NfL--J{I ��JTLP TF,AREA DAYS. PHONE WITH AREA f <br /> oE <br /> ,N C) 13 &3q KT3Xra \ +�� 150 � <br /> PON AREA CODE PHONENWAREA CODE FIRST} GAAT <br /> QIKAP-vi—La., <br /> AP— i�� <br /> s�o ^ <br /> II. PROPERTY OWNER INFORMATION-(MUST BE,OMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> D1 C>arnC�OVQ s <br />�i' MAILING OR STREET=ADDRESS ✓ �_ e1e []INDIVIDUAL LOCAL-AGENCY [] STATE AGENCY <br /> P - L QWORATIDN ©PARTMERSHIP Q COUNTY-AGENCY (] FEDERAL—AGENCY <br /> CITY NAME STATEZIP CODE PHONE WITH AREA CODE <br /> �-WI Sot.! S -Vzbb -Gfo - b>90 t <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 1 S�p1' 11 <br /> MAILING OR STREET ADDRESS �✓,J�,(to��e Q INDIADUAL ©LOCAL-AGE IICY Q STATE-AGENCY <br /> . i�Q CORPORATION [] PARTNERSHIP Q COUNTY•AGEHCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP C DE PHONE#WITH AREA CODE <br /> Q4�za SSb <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cal!(916)3?2-96fi9 II questions arise. <br /> TY(TK) HQ F4—F4- -101 (013 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓6�m ihdram Q 1 5ELF4II5URED ©2 GUARANTEE CD 3 UWRANCE Q 4 SURETY BONO ©5 LETTER OFCREDIT Q 6 EXEMPnON 217 STATE FUND <br /> I, B STATE RIND S CHIEF FINANCIAL OFFICER LETTER I©9 STATE RIND&CERTIFLCATE OF DEPOSIT O 10 LOCAL GOVT.MECtIANISM 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Leo notification and billing will be sent to the lank owner unless box I Or II is checked. <br /> 4 CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILING E.❑ IL❑ NI. ! <br /> TN15 FORM HAS BEEN CO D„p9DTR PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRI 6 SI A E} TANK OWNER'S TITLE DATE MO YlYEAR <br /> 1-` <br /> LOCAL AGENCY US <br /> COUNTY 4 JURISDICTION# FACILITY 0 <br /> LOCATION CODE-OPT70NAL CENSUS TRACT i -OP77ONAL 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 /> OWNER MUST FILE THIS FO” THE LOCAL AGENCY IMPLEMENTING THE UNDERGP" TORAGE TANK REGULATIONS <br /> FORM A 16-95) ii <br />