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STATE OF CALIFORNIA APP ' cO <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A as . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F__j 7 PERMANENT CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 1 <br /> DBA OR FACILITY NAME C NAME OF OPERATOR <br /> Uc _P9 Lit/ Lv' Z u W,--d <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 90 siut-Y, t L aim s?reP i <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ✓BOX 0 CORPORATION [ 'INDIVIDUAL E�:] PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 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 Q 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <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 /> c 1_ V14AIIJ c SIL= zo�7- 5-a/- 2 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ,'NAS/ 1)11Alt/ R LLAd 2=4 s2,- 1414AA1 of e_je� z _ s2_1-yz <br /> II. PROPERTY OWNER INFORMATION-(MUST BE CO"PLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> LA 161 <br /> MAILING OR STR <br /> RADDRESS INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> 3 J Z J f}s 0 CORPORATION 0 PARTNERSHIP (� COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> MUd10s�1 C4. Sd <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> NA of <br /> MAILING OR STREET ADDRESS ✓ box to indicate EkiNDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> ZJ40FA A Ile 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> WITH ARA CODE <br /> clM0cles1© sTATE C4 - 21335–CODEP-'S�S-Z/E�/�Z7 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT O 6 EXEMPTION Ev 7 STATE FUND <br /> D 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM O 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.= 11.0 111.O <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 NAME(PRINTED&SIGNATURE) TAN,�eK�OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> .JAI LAUAR A V JA)tt� � — <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> mI I I 2�z I I U" <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 0,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR*THE LOCAL AGENCY IMPLEMENTING THE UNDERGIR STORAGE TANK REGULATIONS <br /> FORMA(6-95) <br /> f <br />