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Pf.,°V NC�s C <br /> STATE OF CALIFORNIA �P ° <br /> 7 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT Q 5 CHANGE OF INFORMATION a 7 PERMANENTLY CL <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E�] 6 TEMPORARY SITE CLOSURE j J <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME s NAME _OPERATOR <br /> ADDBFF-SS j NEARE CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX Q CORPORATIONINDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR a ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> AY : NAME(LAST,FIRST) r PHONE#WITH AREA CODE DAYS: NAME(LAST,FI T) HON WI REA ODE <br /> _67 <br /> NIGHTS: NAME(LAST, <br /> FIR T) PHONE#WITH AREA CODE NIGHTS: NAME LAST,FI� PHONE#WITH AREA CODE <br /> r /L —6L ? C <br /> II. PROPERTY OWNER INFORMATION-('MUST BE CO"PLFTFD) <br /> N CARE OF ADDRESS INFORMATION <br /> M 14IN STREET DRESS t/ bcxtoi�dm'a DfUIDUAL QLOCAL-AGENCY QSTATE-AGENCYY <br /> fj 1 a Ir AI iQ CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> PHONE-CITY NAME � S ZI'P��� � #WITH �OD�Db� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> Npdq OF OWNS CARE OF ADDRESS INFORMATION <br /> i i t l.- �- <br /> MAILING OR STREET DR S ✓ boxto indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> r d t-t-�F Q CORPORATION Q PARTNERSHIP <br /> COUNTY-AGENCY FEDERAL-AGENCY <br /> CMIE S ZIP C PHONE WI EA COD <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 -1 1 1 1 1 1 1j <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED { <br /> ✓box to indicate Q 1-SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND <br /> Q 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 99 OTHER I <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.El IL l �l p_.III.F1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PR.I-} SIPNA RE)( TANK OWNER'S TITLE DATE MONTHYDAYNEAR <br /> 4 I!-1 t t. �.I✓�jt� t .\w.:"�- ,-`�-rL.��°'°" +���t f� L. �/ ���>7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY It tj°1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY ATL T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROITORAGE TANK REGULATIONS <br />