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STATE OF CALIFORNIA O( I <br /> STATE WATER RESOURCES CONTROL BOARD RECED ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A " <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE MAR 01 <br /> MARK ONLY 1 NEW PERMIT F__j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIOPEN\flB04 RaNL L •CI SED SI <br /> ONE ITEM El 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE PERMIT / SERVICES <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OafACILITY NA#1ME NAME OF OPERATOR <br /> C <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CtD CS d Lip <br /> CITY NAME STATE ZIP CODE / SITE PHONE If WITH AREA CODE <br /> CA <br /> ✓BOX CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If owner of UST is a public agenciowplete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> YS: NAME(LAST, R,S`n PHONE#WITH AREA YS: NAME(LAST,FI T) L _e PHONE WITH AREA DE <br /> V L Z 0 6 <br /> NIGHTS: NA (LAST FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LA T, T) PHONE If WITH AREA C/OD�/� <br /> II. PROPERTY OWNER INFORMATION-(MUST BE CO"PLFTFD) <br /> NAME � CARE OF ADDRESS INFORMATION <br /> L <br /> MAILING OR STREETA DRESS ✓ bcxt3r:a' D;VIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> �i 0 CORPORATION Q PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME \ STATES Y ZIQ�C9O�� �� PHONE ,WITkI ARE-ODE �^ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) `/iJ—If �lJ lf7 CI7 G� 7 <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto indicate 0 INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> e���.QQ CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �c c�L K_� O� tp\ Clt Is— I, O Qaoc�)t-U-1'.CD 9 5 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4—F4- - <br /> V. PETROLEUM!.YW FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Fb,x to indicate 1 SELF-INSURED = 2 GUARANTEE =3 1NSURANCE =4 SURETY BOND Q 5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND <br /> 0 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 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. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJUR;;AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED 8 SIGNATURE) I TANK OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL /L <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 FORAW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOTORAGE TANK REGULATIONS <br /> � <br /> b-23-Co <br />