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® CgOURCl3 <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 ❑ 3 RENEWAL PERMIT 1E<5 CHANGE OF INFORMATION F-1 7 PERMANENTLY .SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 0 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> k� l< S4_ /k-k -pr IL u /c � �.ek��r 7- <br /> ? <br /> � <br /> ADDRESS `,, A NEAREST CROSS STRE PA CEL#(OPTIONAL) Z 17-&d-2 I <br /> IS'd j Ale r_A M4i*v S��zt ti L �.�.9na ec +9 --f 114. <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> A/ e,c1Q CA ��3�6 iC)C/- Z:T -7(4 <br /> ✓ BOX ga CORPORATION Q INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' (]STATE-AGENCY' Q FEDERAL-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 �n Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR [in5 hHFFR OR TRUST LANDS 006 04,5 Cj Z L <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 /> n�cIt., /Ll./c� �/�y - r''7_V_4 <br /> NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> s'Z7-�7� 7 ,I/RvrLo' /cam S'�Ct -i'lc+-0 9T <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 1 ✓ box to indicate INDIVIDUAL LOCAL-AGENCY (] STATE-AGENCY <br /> -?,L/6's- CA'V 64j CaA U�<, J0'T"/­L- =CORPORATION PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SQA/ a - C Cf1 9 S/3 z c�8-ZXe—V4T7 L <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME O OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD ESS ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> /"Q ��x 4-.7 AIs L11boCORPORATION (] PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 91"4,1 3 7cS-iU S'7—d'�i C <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F474- - 0 1 / 1,9'1 7 4 a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION 7 STATE FUND <br /> 6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT O 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: I.❑ II.❑ 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) TANK OWNER'S TITLE ,fly DATE MONTHIDAYNEAR <br /> 1?C t <( 9 7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL _77_CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> .v2 qj a3 <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 /> FORMA(6-95) OWNER MUST FILE THIS FORM W(WrE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNUN$PRAGE TANK REGULATIONS <br /> r. <br />