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esou•c�s <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> 3 't <br /> r r ` COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT a 3 RENEWAL PERMIT GE OF INFORMATION 7 PERMANENTLY SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT a 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACV� V FACILITY NAM; r l tkNAME OF OPERATOR �Ob o } <br /> ADDRESS REST A gOSS EET PARCEL#(OPTIONAL) <br /> CITY NAME STATEZIP DE. SITE PHONE If WITH AREA CODE <br /> La .� ro4 5 �—OY�p " <br /> ✓BOX E-1 CORPORATION INDIVIDUAL [:1 PARTNERSHIP E::]LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If 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 2 DISTRIBUTOR ,' <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> ON <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE If WITH D DAYS: NANE(LAST,FIRST) ,PHONE it WITH AREA CODE <br /> ilI6 <br /> NI61* NAME LAST,FIRST) PHONE If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> tAe <br /> fr PROPEM WNER INFORMATION-(MUST BE COMPLETED) <br /> NtMEI � j � CAR OF ADDF]�SS�ORMATION� 'l„J <br /> (LpI'�NG OR STREET ADDRESS ✓ box7o indicate , INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> �J (`�.x CORPORATION [= PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CI NAM,Y —e c—9� �O(,�. $1A�� ZIP DE PHLS' 1 WITHCODE <br /> � <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> PAMV OF OWNER� �A CAR OF ADD ESS INFORMATION <br /> E��[�►3W�cx r -��� r cru.. d. �- -2�.. n <br /> MAILING OR STREET ADDRESS ✓ box to indicate (DUAL E]LOCAL-AGENCY STATE-AGENCY <br /> P1151 (30"k =CORPORATION Q PARTNERSHIP =COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAMn,� STATE Z _IP S ��� PHONE#W AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMB/ESR-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED = 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 7 STATE FUND <br /> 8 STATE FUND S 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.O it.0 III. <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&SIGN RE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> GD+rJa�d Car zo.. Okine <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY IfEj� O� <br /> / lize . <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 75PV Ft-DISTRICT CODE -OPTIONAL <br /> � a <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 FORTH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRjf STORAGE TANK REGULATIONS <br />