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VRC <br /> 6bC�'RR3 C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT E:] 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME # NAME OF OPERATOR <br /> Q ( fC STOP /2-4- a l - s-T p tq^4z_v_ (s i NC_• <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL)Sac / /0P_-re( <br /> A-I;A fM I<DA- 7_0 - 7_6o -2_1 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> MA/1J1'E CA 475733& 2-09' 823 <br /> ✓BOX CORPORATION INDIVIDUAL = PARTNERSHIP Q LOCAL-AGENCY O COUNTY-AGENCY' [] STATE-AGENCY' a FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #owner of UST is a public age ,complete the foltowing:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR0 RESERVATION!INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS C ZZ <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 /> � <br /> BAKe $ sio &S_,? - S� RW /EL07 MI k--,F (571 t) 5_7 —&5ID <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,'FIRST) PHONE#WITH AREA CODE <br /> B?qV-> Be00 51 D) K 0,A ,1 EL 07.1 ME 44o - oq 31-- <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> &EbI46f ^1MC YAM Asn I rA <br /> MAILING OR STREET ADDRESS ��! ✓ box to indicate INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> Q/J GQ K D�I VeCORPORATION (] PARTNERSHIP OCOUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 5 5oC: q 6­ 4 <br /> l 52 08- 258-6r <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> �v K STo &T5 IMC, <br /> MAILIN OR STREET ADDRESS �✓/box to indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 45(11 ei reap2►SE 5[. U CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE#WITH AREA CODE <br /> e40/V11W7 I CA 4_f53a� S/0- -SSa� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 f4--]- / 8 �T3-1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBIL TY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION M 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =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. 11.0 111, <br /> THIS FORM HAS BEEN OM LETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED I SIGN UR TANK OWNER'S TITLE DATE MONTHiDAY/YEAR <br /> M f l� ,(96Y'r,MN61;'I0k / erNI;`G <br /> LOCAL AGENCY NLY <br /> COUNTY# JURISDICTION# FACILITY If <br /> m F <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 7risOR•DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY ATI ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORjr THE LOCAL AGENCY IMPLEMENTING THE UNDERGRTORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />