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' � � esounces <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> -CSI IFOP N' <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F—] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SI <br /> ONE ITEM El 2 INTERIM PERMIT F] 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME- ^ NAME OF OPERATOR <br /> ADDRESS ^ T� /� NEA t�CROSS STREET M(OPTIONAL) <br /> a <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> ✓BOX Q CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> owner of UST is a public agency plete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR 0 ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESE <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TR STVATION LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DPAY NAME(LAST,FIRST) PHONE#WITH AREA CODE DAY: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> HAA1 Z�`l3 Zoe S21, _0 KNA Al �S�"L-itJj <br /> NIG TS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> K14AAJ 2etg 2-0 1-7 zY-6S/6 NJ A' All SE60 2_®5 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> AIASb!'�M tetQAJ <br /> MAILING OR STREET ADDRESS ✓ bcx to ruse INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 312 d�T s��R A✓c0 Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ZF r3 fj4 A <br /> MAILING OR STREET ADDRESS ✓ boxto indicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 4Wd,L t 4/- L Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ,yTu ��s oI C,4 SZZ2-j <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q s LETTER OF CREDIT Q 6 EXEMPTION IN 7 STATE FUND <br /> Q 6 STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT.MECHANISM Q 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: <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) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> f <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> FF <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 INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FO THE LOCAL AGENCY IMPLEMENTING THE UNDERGR9 STORAGE TANK REGULATIONS <br />