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p C <br /> e wut � <br /> STATE OFCALIFORWA g <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A os <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 2r, NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SI <br /> ONE ITEM a 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE �z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME �OQ` (�� � NAME OF OPERATORKr <br /> P <br /> ADDRESS 2 3& N //„___ ,`� NEA/_xeSSTREET <br /> ® PARC0t(OPTIONAL) <br /> CITY NAMEI—OP/ STATE ZIP CODE SITE PHONE X WITH AREA CODE <br /> CA <br /> ✓BOX <br /> TO INDICATE D CORPORATION =INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY DISTRICTS' COUNTY-AGENCYSTATE-AGENCY' = FEDERAL-AGENCY' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,sedan,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> VIF INDIAN <br /> 8 OF TAVKS AT SIT.P.A. I.D.it(optional) <br /> 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: N(1AijE(LAST,FIRST) PHONE i1 WITH AREA CODE DAYS: NT,FIRS PHONE X WITH AREA CODE <br /> #441(5W C <br /> KW <br /> NIGHTS: NAME(LAST,F T) PHONE i WITH AREA CODE NIGHTS: NAME(LAST, ST) OHOONEX WITH AREA CODE <br /> g -6�2 �' 2U 70- ,o <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> ' NAM � CARE OFADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS / /}� ✓box to Indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> ASK ;ffi�g 236, �� _",VCS CORPORATION PARTNERSHIP =COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME �n' STATE ZIP CODE 04� Y O�QWITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF RNER PCARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRJESS j y ✓box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> J <br /> G 3 Gj /N� blw& �CORPORATION = PARTNERSHIP (]COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME � STALTE ZIP <br /> CODE! S�-/O l'HONEVJITH A CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box ID indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION 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.El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SI ) /ej/2 OWNER'S TITLE DATE MONTH/DAYNEAR <br /> 1-s <br /> LOCAL AGE Y USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m1,311 <br /> LOCATION CODE -OPTIONAL 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 ufttlin6N ONLY. <br /> OWNER MUST FILE THIS FORM E LOCAL AGENCY IMPLEMENTING THE UNDERGROUN AGE TANK REGULATKW <br /> FORMA(3/93) 3 <br /> t.1 <br /> 7 <br /> t <br />