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auA e <br /> STATE OF CALIFORNIA <br /> a <br /> STATE WATER RESOURCES CONTROL BOARD , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE IA <br /> C�l,epN N,T <br /> MARK ONLY f?3I 1 NEW PERMIT O 3 RENEWAL PERMIT F-� 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Cr-V D KI G5l <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA n7 <br /> ✓BOX CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' 0 STATE-AGENCY' 0 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 otrice which operates the UST <br /> TYPE OF BUSINESS �g 1 GAS STATION Q 2 DISTRIBUTOR a ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION f^wic <br /> 0 3 FARM Q 4 PROCESSOR a 5 OTHER OR TRUST LANDS tCJli <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 9CO -23 - ® 2.5 <br /> NIGHTS: t4AME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1 'uoj- <br /> 11. PR PERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME > fie <br /> CARE OF ADDRESS INFORMATION <br /> Ae <br /> MAILING OR STREET ADDRESS ✓ box to indicate []INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY_NAME STATE ZIP ODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CAREDF ADDRESS INFORMATION <br /> r—VT&PC/C-rc, G2Z22RA9t r <br /> MAILING OR STREET ADDRESS ✓ boxio indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> B V e /%o O CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME N STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions aris 9Z5 <br /> TY(TK) HQ M44- -10 'b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to mate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION O 7 STATE FUND <br /> 0 8 STATE RJND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 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: 1.0 II.ED M. <br /> t THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> 'S NAME(PRI E & i ®G TANK O ER'S TITLE✓ DATEl MONTI, DAY/YEAR og 3 Pa <br /> Z <br /> L AGENCY U LY <br /> COUNTY# JURISDICTION# FACILITY# <br /> EE <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AjaST(1)OR MORE PERMIT APPLICATION- FORM B.UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FO THE LOCAL AGENCY IMPLEMENTING THE UNDERGROT <br /> ORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />