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sat .• 'Y : `{_ ,4 r { �yf_Te, <br /> t OURcc3 <br /> STATE OF CALIFORNIA A�P . cO <br /> STATE WATER RESOURCES CONTROL BOARD W dam, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A s . , ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM El 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D A OR FACILITY NAME N, E F OPERAT,QF1 <br /> �'AE 04 NSi4iivhl W6201'3(?2 "PrW&\j <br /> p WSS 7H <br /> ST <br /> NEAREST CROSS STREET PARCEL If(OPTIONAL) <br /> CI /�(C!/ STATE /�J 3 / 4D �[JH E 3�� V <br /> CA <br /> ✓BOX 4NI CORPORATION O INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-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 0 2 DISTRIBUTOR RESERVATION <br /> INDIAN #OF TANKS AT SITE E.P.A. �. 001171F.3D.#(optional)3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P ONE#WI AR CO E AY NA E(LA T.FIRST). PH #WITH REA COD <br /> . 1 I <br /> d'3� ���/ r�rJ�T. <br /> `-�a3 <br /> HTS: AME(LAST Fl ST) ONE#WITH AREA CODE G S: N E( FIRST) PHO WITH AREA CODE <br /> -Ars 6 -/Y3/�" ����rnEA& <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> I.NG OR STP41ij ADDRESS ✓ box to indicate Q INDIVIDUAL 0 LOCAL-AGENCY = STATE-AGENCY <br /> 01 O X \306 0 Q CORPORATION 0 PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br /> 'IT,Y ST�7 Z (oS `_, PHONE#WITH AREA CODE <br /> Oct <br /> lie <br /> III.LTANK OWNN�ER)INFORMATIO-N1-(M�U^ST BE COMPLETED) <br /> ( / <br /> i W�.J � L)(L CV1t�M <br /> NAME OF OWNR <br /> ESS IjAT <br /> M4.�L�,JIG OR STR DDRESS V, box indxate [0•INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ' 0 . ox i/,W QQ 2�CORPORATION =PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CW`NAM 110 <br /> A frT ZIp,6 �� ��#CJ 7CQC <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F41-4--l-14001 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate = 1 SELF-INSURED O 2 GUARANTEE =3 INSURANCE Q 4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> =8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM E:1 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. Ill• <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 RINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> /112A ,<� 4S i . o� /P - X17 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m F77 1111m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT (1)OR MORE PERMIT APPLICATION- FORM B,UNLESIS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU TORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />