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P,,OUR <br />C C <br />STATE OF CALIFORNIA Ar <br />STATE WATER RESOURCES CONTROL BOARD a <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />Yn <br />• C�(IFOR N.r <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY F—] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 2 INTERIM PERMIT F__1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 9 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA N <br />��, ` � ILITY #11191 <br />NAM F 'EAT <br />' <br />EGokeen mith <br />AD9`09 E. Hammer Lane <br />NEARESTCRonggET <br />PARCEL#(OPTIONAL) <br />CITYgj1MAE won <br />ST <br />ZIP COD§5209 <br />,$jT�PyO� #y1 11REA CODE <br />San Francisco <br />CA <br />415-773-7834 <br />��[[,yy <br />T INDICATE L�y�tSORPORATION INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY COUNTY --AGENCY STATE -AGENCY FEDERAL -AGENCY FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br />= ✓ IF INDIAN <br /># OF TANKS AT SITE <br />P. A. I. D. X (optional) <br />0 3 FARM 0 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR' LANDSA <br />LE. <br />AL 000 039 099 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />SILVA LARRY 1-206-442-7160 <br />✓ box ID indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />BP Emer en Desk 1-800-274-3572 <br />STATE ZIP CODE <br />If. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NA <br />first Interstate Bank of Ca <br />CARE OF ADDRESS INFO RMA ION <br />Iry oxerbaum <br />MAILING OR STREET ADDRESS <br />✓ box ID indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY <br />345 California St 8th Fir <br />CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY <br />CIN NAME <br />STATE ZIP CODE <br />PHONE # WITH AREA CODE <br />San Francisco <br />A 94104 <br />415-773-7834 <br />WTTANK OWNER INFORMATION - (MUST BE COMPLET <br />NAME OF OWNER <br />Tosco Northwest Prop. I Inc. <br />CARE OF ADDRESS INFORMATION <br />LARRY SILVA <br />DATE MONTH/DAYNEAR <br />MAILING OR STREET ADDRESS <br />✓ box b indicate INDIVIDUAL <br />0 LOCAL -AGENCY STATE -A Y <br />601 UNION STREET, STE 2500 <br />CORPORATION PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGE <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />SEATTLE <br />WA <br />1 98101 <br />1-206-442-7160 <br />IV, B F EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 1414 1-10 1316121 4 4 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ <br />box IDindicate1 SELF-INSURED 2 GUARANTEE 3 INSURANCE (] 4 SURETY BOND <br />5 LETTER OF CREDIT 6 EXEMPTION 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 JIYx <br />APPLICANT'S NAME (PRINTED & SIGNATURE) <br />APPLICANTS TITLE <br />DATE MONTH/DAYNEAR <br />CHESTER BENNETT <br />I RETAIL ENGINEER <br />1 :71 <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />7_1 FTTI LZRo <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 />FORM A (5-91) FOR0033A-5 <br />