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S-iATECFCAUFORNIA a ••••'`� <br /> t <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/S17E <br /> NEN PERMIT (� 3 RENEWAL PERMIT s CHANGE OF iNr7RhAa^C."� 7 PER.to <br /> NTLY OS=D S <br /> {ARK ONLY — <br /> ONE ITEM INTERIM PERMIT n s AMENDED PERMIT 5 TEMPCRARY SITE CLOSURE <br /> I. FACIUTYISITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> CBAAC; Ty:aME NAME C<GPE-ATOR <br /> I <br /> ADDRESS -�� �-7 NEAREST CRCSS o,HEFi PAACSa(CPTICNAL) <br /> C;TY.Na ESTATE ( ZIP CCOE t?EPHCNE X WITH AREA CCCE <br /> CA <br /> ✓ BOXCC;,--C„ArCN C u4cmcuAL PARTNERsH;P LccAL•AG2CY CCUNrf -G_;CY• _STATE-AG'-QNCY• (-FEDERAL-AGENCY' <br /> 1-0 INDICATE OISRICra <br /> 8 owrter at UST s a ouo5:agwc/,:moiete me fodowniq:ams of swemsor of dMsion.sacro at criee wncn coerates Ofe UST <br /> TYPE OF BUSINESS _ C• ✓IF iNCIAN v OF TANKS AT SI—,E F P.A. 1.D.a(ccricnat) j <br /> L_ t ,..5 s.ATIGN 2 DISTRIBUTOR <br /> RRUST <br /> -SF-:;VA-,,CN <br /> 3 FARM C s PROCESSOR C i OTiE9 OA TRUST LANDS <br /> Ef.{ERGENCY CONTACT PERSON (PRIMARY) E.MEaGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: ^LAME(t •ST-FrRS T j / PHONE a WI T-I AREA CCCE GAYS. NAME;L AST.FIRST+ PHONE#WITH AREA C:CE <br /> :NIGHTS: NAME'LASTIF PHONE f WITri AREA CCCE I NIG!-iTS: ,NAME:'.AST.FIRST, PHONE+WITH APEA CCCE j <br /> i. <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETE-0) <br /> NA % CARE-::F:CCRESS INFORMAi.C.N <br /> MAIUN R STH--ACCRES3 I ✓ :as:a z,riata ,1NOC11CUAL _:.^.Cnl•+iG'c.�iCY C STATE-rGEr;C: <br /> 53 CC;;PCAAT�CN PARNc-:HIP CCUNTY-AGENCY C FE,:c^nAL•AG@IC'.' <br /> C; Y NA I STATE ZIP CODE i PHONE o WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMW CARE OF ACCRESS iNFCRMA T;CN <br /> 17 &•' —c ;�- _ <br /> MAIL'N STr==T AGD^nE=S I ✓.xuto91=3 WOmCUAI _ -::CAL-AGENCY I_ STH--AG�7CY <br /> J 5 I i C^^n?CRArCY _PAR.E:.tr.:P _ ;(:NT!-AGENCY C P=c3AL-AGENC' <br /> C; y NA STAB" 1 ZIP COLE ?HONE..i WITH AREA CCCE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cail(4 i o)322-9e6-9 ii GuesSors ansa. <br /> TY(TK) HO <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLEi cJ)—IDENTIFY THE METHODS) USED <br /> ✓b:to m0irate <br /> I SE},;NSURED CI Z GUARANTEE Q 3 INSURANCE =4 SURETfSONO C 5 L_. —,CFCRE:jT C o ;:(EMPTICN C 7 sTATE,UNO <br /> C 8 SA,.TUNO 5 CHIEF RNANCIAOFRaR Lm;TER Q 9 SATE FUND&CEO.iFr.AT-e CF DEPOSIT = 10 LOCAL GOVT-MECHANISM OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and biiling will be sent t0 the tank owner uniess box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOT)FICATICNS AND BILLING. I. It. ul. <br /> THIS FORM HAS SE-;=N COMPLETED UNDER PENALTY OF PE?JURY,AND TO THE SES7.OF MY KNOWLEDG$IS TRUE AND CORRECT <br /> TAN ONums NAME(PRINTED&SIGNATURE) !/ TANK OWNERS TITLE CATS=M0Xr1VWOAYq'P-AF;Qlz <br /> L66 GEiVCY USE ONLY <br /> � <br /> COUNTY* JURISDICTION x FACIL 7f k �,1 ? <br /> LOCATION CODE -OPTTONALCENSUS TRACT F-OPT70NAL I SUPVIS OE-OPTTCNAL <br /> THIS FORM MUST SE ACCOMPANIED BY ST(t)OR MORE PERwrAPPUCATiON- ORM B,UN IS IS A CHANGE'OF srm INFORMATION ONLY. <br /> OWNER MUSTFiLETHIS FORM SMITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRGJND 5i ORAGETANK REGULATIONS <br /> FORM A(6.95) <br />