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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGETANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ' <br /> •C1l t•OA N,� <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C76 <br /> .69 <br /> MARK ONLY ❑ ❑ ❑; ❑ rtt <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> t.A w 0$-15" t i C-)C— <br /> A ?)0 , p � � M=9 ' NEAREST CROSS STREET P `#(OPT ) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WI AREA CODE <br /> L00t ,/ CA 41 '2'� a'- � r" .;W-j'3 <br />'E ✓BOX CORPORATION INDIVIDUAL � PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY' O 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 ✓IF INDIAN #OF TANKS AT SITE E.P.,W �D.#(optional) Cgs„ <br /> RESERVATION s E+ Q <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> I EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> 5. NAME <br /> ��% FIRST) PHONEWITH AjR�F4,CODEDAYS: NAME(.LAST,FIRST) ' P NE#WITH AREA COb <br /> A( P a�A ' CW•O1, wMr ��p44C1< I1I � /;•`++� <br /> NIG TS: NAME LAST,FIRST) � HONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> C <br /> NIG TS: 0j . 4" 2.01�1) -'• `•off G, c,"4 , wt�n. <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMpEE �,�11,��,�+��— / CARE ADDRESS INFORMATION <br /> It <br /> MAILING OR STREET ADDRESS Q 1 1"14 <br /> ✓ box to indicate IVIDUAL [:1 LOCAL-AGENCY Q STATE-AGENCY <br /> I S, r 1 C CONN ` ,4 "�`�47-- r Dq'CEORPORATION PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME <br /> O I h S hP CODE 1272+2 <br /> P r I�J+4 CODE <br /> P✓�i <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) ' <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br />{ MAILING OR SIREET ADDRESSg+ �.�,,,4 ✓ box to indicate =,,W]VIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> t� cvP►I� A\ ;-., Q CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> i <br /> CITY NAME STAT ZIP PHONE#WITH CODE 'I <br /> -60 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - 2 6 <br /> l <br /> a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> L✓box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION F7 STATE FUND <br /> 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT O 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.FO 111.❑ <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(PRINTSA A S1A E) TANK OWNER'S TITLE DATE NTH/DAYNEAR <br /> =Q� I Af-f.-A. <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> -� ry '4 `-t(49 <br /> LOCWLN CODE -OPTIONAL CENSUS RACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> . zt .60 -,gyp <br /> THIS FORM MUST BE ACCOMPANIED BY ATL ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORIW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWTORAGE TANK REGULATIONS <br /> i <br />