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PemouR c <br /> STATE OF CALIFORNIA .P o <br /> STATE WATER RESOURCES CONTROL BOARD w , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "° <br /> •CSI IFpP M`� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS f <br /> ONE ITEM 2 INTERIM PERMIT F__j 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ,! <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB ACIL1TY� E f� 1,�(• / NAME IF OPERATOR <br /> ef <br /> ADDR SS ((//CC//�, 1L / NEAREST 6, <br /> -OSS STREET PARCEL#(OPTIONAL) <br /> �ao Lo "se .T=- S <br /> CITY yAME STATE ZIP DE S TE PHONE#WITH AREA CODE <br /> L-q N roCA 5,330 6Zo9 <br /> ✓ BOX CORPORATION INDIVIDUAL (] PARTNERSHIP (] LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY OFEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> TYPE OF BUSINESS X 1 GAS STATION 0 2 DISTRIBUTOR / IF INDIAN #OY AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY/)-optional <br /> D S: NAME(LAST,FIRST) PHONE#)ITH AREA CODE D NAME(LAST,FI ST) ` _?166631 x`79�5r bc, bia /Uasse{1 .za 9 `183--x381 CL4 s l ' <br /> NI HTS• NAME(LAST,FIRST) PHONE#WITH AREA CODE�� NIGHTS: NAME AST,FIRST) goo .27q_3-57a <br /> y�i�. Pier ens f9nD—a7L/- o2�/�r, e►Hc en 7 <br /> II. PROPERT OWNER INFORMATION- MUST BE COMPLETED <br /> NAMECA E OF ADDRESS RMATION <br /> MAILING OR STREET ADDRESS -/� ✓box to indicate = INDIVIDUAL = LOCAL-AGENCY = STATE-AGENCY <br /> 6 8 QS P� Ar G —39(f) CORPORATION �Q PARTNERSHIP (]COpUNTY-AGE/NCY? (] F—ED7ERAL-AGENCY <br /> ODE PHONE <br /> WITH <br /> CODE <br /> CIT�jIQ4a O ��i/(�[d Lf ST TE ZIP CJ 167 7D f(7[�#E7cJ�EAQ /�3 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME <br /> F WNER C61REOFADDRE NFORMATION <br /> WCC/J�e 4-41biS rctis'i <br /> MA N OR STREET DDRESS ✓ box ID indicate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> /O eC J /e- !/Y, ✓ ,�pO CORPORATION PARTNERSHIP COUNTY•AGENCY 0FEDERAL-AGENCY <br /> CI ME STALE ZIP.CODE P ON E#WITH A CODE <br /> G J <br /> L ✓ a 733 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4]4]- 6 ,2 d <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box ID indicate 1 SELF-INSURED =2 GUARANTEE (] 3 INSURANCE A SURETYBOND <br /> 5 LETTER OF CREDIT =6 EXEMPTION Q 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 /> APPLICANTS nNAME(P�INrED 8 SIGN TURE�� I APPL���TI� � DATE MONTH/DAYIYEAR <br /> 01 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# AIC t S 1161 <br /> Y51 1 1 111 ss � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0 3 07_& �_ -SZ <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(5-91) <br /> FOROMM-5 <br />