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�you�aea <br /> STATE OF CALIFORNIA :r , <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE6. <br /> •C�I,FOP�'� <br /> MARK ONLY ® 1 NEW PERMIT F1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F—] 7 PERMANEN Y CLOSE .SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME {� NAME OF OPERATOR <br /> C;N�'�/ �N MANaArc-erk. <br /> ADDRESSNEAREST CROSS STREET PA ICEL# (OPTIONA <br /> 57555 <br /> �55 �, H�M� L A H M t <br /> I� >L MA-N VA'D <br /> CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE <br /> tzK �fJ CA 95:Z I2 NEw <br /> ✓BOX CORPORATION E] INDIVIDUAL 0 PARTNERSHIP F7 LOCAL-AGENCY 0 COUNTY-AGENCY' Q STATE-AGENCYFEDERAL-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 2 DISTRIBUTOR a ✓IF INDIAN J#OFTANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION I 2 <br /> Q 3 FARM 0 4 PROCESSOR Q 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) PHONE#WITH AREA CODE <br /> I - o E II tSTiN-Lq7 c N 8�, 17-3- �jSZB <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> �� c LI goo 231 -c7loZ3 I�hbG t.i gt7o 231 -023 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME mC I CARE OF ADDRESS INFORMATION <br /> 5 Cry - <br /> MAILING OR STREET ADDRESS <br /> ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> acv Y L L V I <u I c-" 1© CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 67-5) <br /> ONE#WITH AREA CODE <br /> � <br /> IF'd !ILL GA o1 G�1 cA125164- I F7-11- <br /> 111. <br /> -12-III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNERC-T Cfl, CARi IOFi D`REBS INFORMATION <br /> GetrN <br /> MAILING OR STREET ADDRESS - ✓✓/box ttoindicate D�VGyIN'DSIVIDUAL QLOCAL-AGENCY 0 STATE-AGENCY <br /> C1>1 U CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITHAREA CODE <br /> � I cpc g 3 C�zS >`I-2 CC) <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - 3 I 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> be box to indicate 1 SELF-INSURED =2 GUARANTEE =3 INSURANCE Q 4 SURETY BOND =5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND <br /> = 8 STATE FUND&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: I.= it.0 III. <br /> A40-ITTHIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK EIWMER'S NAMEPRINTED&SIGNATURE) TANK 9W"M'S TITLE DATE MONTHIDAYNEAR <br /> )3l KK KPSOkI13 II-I(-9g F1 Rs 5usm1'fTM.- <br /> L I✓ N c- IML 3E L of—1 — 9 2_. 5uvamnTA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 8 <br /> EE D 19 13 1E I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BF ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORM*HE LOCAL AGENCY IMPLEMENTING THE UNDERGROU RAGE TANK REGULATIONS <br />