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0 ESOURG�S <br /> STATE OF CALIFORNIA - <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> CR�IfOR N.r <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [:j 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAM NAME OF OPERATOR <br /> B l � <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3300 tt2a_t,�,j lco <br /> CITY NAME STATE ZIP CODE SITE PHONE It WITH AREA CODE <br /> _ S hoz fc ,I/ BOX <br /> n CA <br /> To INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY F-1 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.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 /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> /Ve(,J-�Oh a --_'i�d-oa S� Pwr <br /> NIGHTS: NAME(LAST,FIRST) Li PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> slit I'I —e- rv%S PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS / ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br />' P,0 / �J(�IC CA06 Ej co A 10�Cp Y =CORPORATION PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> n 9331-U (o Zv 9 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> _ _57 c, re aS cZj — <br /> MAILING OR STREET ADDRESS• ✓ box b indicate INDIVIDUAL LOCAL-AGENCY (]STATE-AGENCY <br /> SGG 0 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE#WITH AREA CODE <br /> • <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L44�41-[ - 0 o o 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate L—' SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> CJ 5 LETTER OF CREDIT 6 EXEMPTION 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.❑ it. I. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# gL,q Cd 33 <br /> 3i T <br /> LOCATION CODE OPTIONAL I CENSUS TRACT_# --OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> v/ 3a3 GAO 3 I <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 /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU D STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br />