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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 3s <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> CSL IIOww" <br /> MARK ONLY F-1 1 NEW PERMIT 3 RENEWAL PERMIT jEf5 CHANGE OF INFORMATION a 7 PERMANENTLY TE <br /> ONE ITEM O 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> I. &j IFc-( j D T). POSE� <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> HA1 L3 ST . <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 'VI-Poo CA �`)D� (209) Sqq -L+qS <br /> ✓BOX CORPORATION Q INDIVIDUAL O PARTNERSHIP (] LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 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 XX 1 GAS STATION 2 DISTRIBUTOR Q ✓IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION 2- <br /> 0 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUSTIANDS N/A <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: N T FIRS. _-_ PHONE#WITH AREA CODE <br /> 2c�q) ;29-2>2_ <br /> >Z I )S` 9 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NI PHO E#WITH AREA CODE <br /> ('02 <br /> qID <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME ARE OF ADDRESS INFORMATION <br /> LLOIQ ENTERP�-IS <br /> AI OR STREET ADDRESS <br /> O Q t ✓ box to lodwate Q INDIVIDUAL I� LOCAL-AGENCY OSTATE-AGENCY <br /> .O. BOX 8 0 8 CM CORPORATION Q PARTNERSHIP D COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE 70DE PHONE#WITH AREA CODE <br /> RTIN CA94553 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER _ —.- CARE OF ADDRESS INFORMATION <br /> ILL ES LLC <br /> R SSp pay ✓ box to indicate Q INDIVIDUAL I� LOCAL-AGENCY 0 STATE-AGENCY <br /> X H O V EM CORPORATION 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CI PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if qes iounse. <br /> TY(TK) HQ4 4- - _0 1!i 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate M I SELF-INSURED = 2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND = 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE RIND <br /> =8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER = 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.0 II.® III.YJ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> TANK OWNER'S NAME PRINTED E) ANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> AelndtZ� HS&E REPRESENTATIVE91 — <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 3 <br /> m FTTI mi 1141!111 <br /> I . <br /> LOCATION CODE -OPTIONAL ____jCENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL ^f <br /> THIS FORM MUST BE ACCOMPANIED BY AT L 1)OR MORE PERMIT APPLICATION- FORM B,UNLESS Ta A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FORM WIWE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN RAGE TANK REGULATIONS <br />