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w b STATE OF CALIFORNIA .P oti <br /> STATE WATER RESOURCES CONTROL BOARD Y dam, <br /> AUgNISEIMOUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> LCOMPLETE THIS FORM FOR EACH FACILITYISITE t� <br /> MARK ONLY 7-1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 02 INTERIM PERMIT = 4 AMENDED PERMIT �����"lll 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 6k-W t-cm ro w n. <br /> ADDRESS NEAREST CROS STREET PARCEL#(OPTIONAL) <br /> l 6 � . 11 St-- 60maA �c' \o <br /> CITY NAME STATE ZIP CODE SI E PHO #WITH AREA CODE <br /> �,r-0 CA qS 3�d �20� 936 - 3l 81 <br /> ✓BOX teCORPORATION Q INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> B 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 a 2 DISTRIBUTOR 0 ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON PRIMARY EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D"AY$: NAME(LAST FIRS-q PHONE#WITH AREA CODE DAY NAME(LAST,FIRST) P ONE#WITH AREA CODE <br /> 01Wwr ate.-G,wc�•.u— o0 23-- 6 1I <br /> NIGHTS: NAME(LAST,FIRST) PHO E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) L #WITH AREA CODE <br /> 0o Z 3 I —DMZ 3 <br /> II. PROPERTY OWNER INFOR TION-(MUST BE COMPLETED) <br /> NAMECARE OF ADDRESS INFORMATION <br /> PO,C_z Z Uj <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0- 6 pX �D6 O 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME /� / STATE ZIP CODE PHONE#WITH AREA CODE <br /> o r f L��c/i.. 6A 9 26 5 f3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER Pry O M CARE OF ADDRESS INFORMA N _a ^G� <br /> MAILING OR STREE ADDRESS / ✓ box toindcate <br /> I0 INDIVIDUAL / I� LOCAL-AGENCY a STATE-AGENCY <br /> Q„ p)C 6 C)C)�- CORPORATION a PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE P NE# ITH AREA CODE <br /> \019A -C e-4 9 d 92s" 8 Z u Dom <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -10 1.3 1 2 I3T¢I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT O 6 EXEMPTION =7 STATE FUND <br /> B STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT = 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: 1.❑ It.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> ZANK49WHEfl5 NAME(PRINTED&SIGNATURE) i*KIOWMERS TITLE DATE MONT AYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIO ONLY. a ' <br /> OWNER MUST FILE THIS FOR TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO ` STORAGE TANK REGULATIONS <br /> FORMA(6-95) l <br />