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STATE OF CALIFORNIA A °; <br /> STATE WATER RESOURCES CONTROL BOARDo <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A `a .- <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> k DBA OR FACILITY NAME NAME OF OPERATOR <br /> I �a N\J <br /> ADDRESS NEAREST CROSS STREET PARCEL a(OPTIONAL) <br /> CITY NAME STATE ZIP CODEITE PHONE#WITH AREA CODE <br /> u k\ CA <br /> 9 5 5 �Z� <br /> ✓BOX CORPORATION INDIVIDUAL PARTNERSHIP E:1 LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> UST is apublica a ) <br /> F <br /> If owner of 'y' Y, '4., <br /> 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 .1IF INDIAN I It OF TANKS AT SITE E.P.A. I.D.If(optional) <br /> RESERVATION 4 <br /> 0 3 FARM � 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EM!1G CY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D M S f PHONE#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 /> v\),"L�, --uNa (Zv�� 4(, -3I,o& <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> t --'�o N2 L\\\J G'JL1, ( <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> J ` \0 (]CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE HONE WITH AREA CODE <br /> i7v \1\ L: A5v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S P' zu L-v i s i <br /> MA)LING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL [�LOCAL-AGENCY STATE-AGENCY <br /> '/T1 =CORPORATION Q PARTNERSHIP ( ,COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE w 3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT O 6 EXEMPTION [=]7 STATE FUND <br /> 0 B STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 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 ONTHYDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT If -OPTIONAL 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 /> FORMA(6-95) <br /> OWNER MUST FILE THIS FORTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROI#STORAGE TANK REGULATIONS <br /> - <br />