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• UMC�S { <br /> STATE OF CALIFORNIA <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD w dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 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 /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE P ONE#WITH AREA CODE <br /> ; 7 Ca 152U5o� � G�3 - 37`t' <br /> ✓BOX CORPORATION E] INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' (] STATE-AGENCY' (]FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS1pt <br /> N owner of UST is,a public agency,complete the following:name of supervisor of division,section or office which operates t7k ��he UST `{ �\ r� r `)� <br /> TYPE OF BUSINESS 0 1 GAS STATION 0 2 DISTRIBUTOR a ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM a 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST)_ HONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i SNS <br /> NIGHTS: NAME(LAST,FIRST) ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> C)Y\ L\ L.\NE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 5 fa.(U (J L.\ C (i <br /> MAILING OR STREET ADDRESS ✓ box to indcate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> G , -it) U x , P­�)U =CORPORATION PARTNERSHIP t COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE ,PHON #WITH AREA CODE <br /> 70CKl011ti1 2U � <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> L-vr N Lou N 7 <br /> AILING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> CORPORATION PARTNERSHIP •COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> 7v � hidtl� CA � �zv5 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate O 1SELF-INSURED =2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION 0 7 STATE FUND <br /> 8 STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM O 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: L❑ 11.ft 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) n TANK OWNER'S TITLE DATE M NTHIDAYNEAR <br /> y 1 f<� I�Gtr r -'; C1rY l J G--�.N t -U t\ U W N E � I , e <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTTI <br /> LOCATION CODE- PTIONAL CENSUS TRACT# -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 /> OWNER MUST FILE THIS FORIF THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO*STORAGE TANK REGULATIONS <br /> FORMA(6-95) <br />