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r - STATE OF CALIFORNIA <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY C <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 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 /> JZo Cu�CiwS-�1���uN tvi U\N i C)�\ <br /> Ij ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> L 1 C 1\J\� tL�UfJ N'j n5LOS <br /> If CITY NAME CODE SITE PHONE#WITH AREA CODE <br /> 5 C)a\C-i U t� 2 v <br /> ✓BOX E�]CORPORATION 0 INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' (] STATE-AGENCYFEDERAL-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 t/IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM a 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EM E SON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST, ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) /� ��PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (J ` � ' (]CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE`#WITH AREA CODE <br /> C ��i U\t� C f\ 52v 0 1 �o ' 31vCo <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER' CARE OF ADDRESS INFORMATION <br /> 5A1\ = L\� 000N 7� <br /> MAILING OR STREET ADDRE S ✓ boxto indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> '���L_r: � 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE El <br /> NE WITH REA CODE <br /> 5�0�_V\7 c� C �\ (,IS zo ( � �- 1t0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ <br /> F44- <br /> V. <br /> 4-V. PETROLEUM UST FINANCIAL RESPONSIBILFY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate [:] I SELF-INSURED [�:)2 GUARANTEE nj INSURANCE [::]4 SURETY BOND 0 5 LETTER OF CREDIT E:]6 EXEMPTION 0 7 STATE FUND <br /> El 8 STATE FUND&CHIEF FINANCIAL OFFICER L TTE1 E:D 9 STATE FUND&CERTIFICATE OF DEPOSIT D 10 LOCAL GOVT.MECHANISM = 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. III.❑ <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(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYN AR <br /> \ i P P,L•t (-� C .N Ft,� OW NE_` 2 2Z 8 <br /> LOCAL AGENCY USE ONLY _R <br /> COUNTY# JURISDICTION# FACILITY#395y <br /> Z 3I I II. <br /> LOCATION CODE-OPTIONAL CENSUS TRA T#!•O�AL SUPVISOR-DISTRICT CODE-QeIIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM�B,,,U/NNL]ESS THIS SIIS A CHANGE OF titE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROIWTORAGE TANK REGULATIONS <br /> FORM A(6-95) ^—,;0 ! � 9 <br /> A4 <br />