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.0 C' <br /> STATE OF CALIFORNIA At <br /> STATE WATER RESOURCES CONTROL BOARD der0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 17] 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE nM 1:1 2 INTERIM PERMIT F_-] 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R FACILITY ME NAMEOF OPERATOR 0 <br /> A t'_ <br /> 0 1-17" <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> C <br /> L QAaQ <br /> CI AME STATE _TZIP CODE SITE PHONE#WITH AREA CODE <br /> CA <br /> t/BOX E:1 CORPORATION F!' INDIVIDUAL [::) PARTNERSHIP LOCAL-AGENCY F-71 COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> 9 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 �l GAS STATION Q 2 DISTRIBUTORF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> IF <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 471— <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAXS: NAME(LAST,FIR Sj; PHONE#ISITFJAREA.CODE- NY - NAME(LAST,Ft A, PHONE E*WITH AREA CODE <br /> AV' r - <br /> 41Z OL)nHA <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NI TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AvrAc 2,,_q_ qazoVqSQ A\Af nore. go t-i e I- Z07- v Irz <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME < 45 14 e-1 CARE OF ADDRESS INFORMATION <br /> mP_ Amm STATE-AGENCY LOCAL-AGENCY 177 E::] <br /> MAILING OR 9TREET ADDRESS wo'VI—I)UAL <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> STATE <br /> CI ZIP ODE_ PHONE#WSW AREA CODE <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWT0& tU A CARE OF ADDRESS INFORMATION <br /> MAILING OR SfREETADDRESS V box to indicate 0INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION PARTNERSHIP O COUNTY-AGENCY Q FEDERAL-AGENCY <br /> 9 CITYNAME STATE I ZIP CODE PHONE#W E <br /> Z47co�, C t7 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4F41- -1 I 1 1 1_7'�; <br /> F <br /> V. PETROLEUMOWST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> V box to indicate 1 SELF-INSURED =2 GUARANTEE =31NSURANCE =4 SURETY BOND = 5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FL <br /> ND <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 11 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 /> l <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTFIIDAYIYEA�R�Ak V7A? y -1 <br /> 0 14A, Is X*� <br /> AS <br /> A <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL IS TRACT# -OPTIONAL 7UPVISOR DISTRICT CODE -OPTIONAL <br /> I — — <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />