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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s r <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> 9 <br /> COMPLETE THIS FORM FOR EACH FACILrrYISITE <br /> MARK ONLY P< 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLO ITE <br /> ONE REM F1 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 40; l <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATO <br /> IN VJS .S onc SAD6 Pp oI, <br /> ADDRESS NEARESTCROSS STREET PARCEL If(OPTIONAL) <br /> or a <br /> CAME STATE Z�OSE � SITE a WITH AREA CODE <br /> /)////// A CA S 2 2,-3!9 95-757 <br /> V BOX <br /> TOINDICATE CORPORATIONr INDIVIDUAL E]PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' (�FEDERAL-AGENCY' <br /> 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 0 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION r <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER ORT LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 6't NQrz5 6$'51 <br /> GHTS: NAME(LAST,FI PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ( - c C Z09 90 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NPAE CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box bindicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 7- it <br /> V CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> C7n STATS ZIP OpE��� PHONE s WITH AR CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) Gr1T S <br /> N OF OWNE /� CARE OF ADDRESS INFORMATION <br /> /vim` ✓� <br /> MA ANG OR S R ET ADDRESS /" ✓ box ID indicate INDIVIDUAL Q LOCAL-AGENCY E::]STATE-AGENCY <br /> p')� � CORPORATION PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CIN r STgTEA ZI / ( �� PSN ! H z /_ODE/9's-75- <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3322-9669 if questions ariisse..1, L <br /> TY(TK) HQ M44- - -2-H-1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box 10 Indicate 1 SELF-INSURED ®2 GUARANTEE =3 INSURANCE (]4 SURETY BOND <br /> 5 LETTER OF CREDIT (]6 EXEMPTION 99 OTHER VU 1A <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.0 II.F] III. <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 8 SIGNED) ` OWNER'S TITLE DATE MONTWDAYNEAR <br /> — 2 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#06`(6,2 5- <br /> 3A <br /> 3A aaLl IA1,31 4 2 <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 00 SITE I fUATK1N ONLY. <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUSTORAGE TANK REGULATIONS <br /> FORMA(3193) f-0ROaf3A-R7 <br />