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STATE OF CALIFORNIA ,• �*� <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE :d ' <br />MARK ONLY rr 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY LOBED. SITE <br />ONE ITEM u 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br />L FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DSA OR FACILITY N9ts1E /� / �- <br />�/ `/ <br />NAME OF OPERATOR <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL (OPTIONAL) <br />CITY NAME <br />STATE <br />ZIP CODE <br />0 � <br />SITE PHONE Y WITH AR CODE <br />i¢C <br />CA <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />?-� 79'/t <br />✓ BOX CORPORATON 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL -AGENCY O COUNTY -AGENCY' O STATE -AGENCY' O F DERAL-AGENCY' <br />TO INDICATE DISTRICTS <br />' 9 omerol USTIs a public agnxy,=91ale Na IcBcwlnG namedsupoK colcrw4ion,satbnoro8ka Akhopenlas Ns UST <br />TYPE OF BUSINESS 0 T GAS STATION 0 2 DISTRIBUTOR <br />IF <br />0 <br />M OF TANKS AT SITE <br />E. P. A 1..0.(0 (opllona <br />0 3 FARM �\4 PROCESSOR Q 5 OTHER <br />RESV ERVATION <br />OR TRUST LANDS <br />FT <br />l / / <br />/p 13 ? 2-1-1 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON -(SECONDARY) -opt Onal <br />DAYS: NAME (UST, FIRST) <br />�9rU, J <br />PHONE Y WITH AREA CODE <br />�o 3 7 17 <br />DAYS: NAME (LAST, FIRST) <br />PHONE Y WITH EA CODE <br />=]7 <br />LAST, <br />NIGHTS: NAME(FlRS'f) <br />PHONEY WITH AREA CODE <br />NIGHTS: NAME (LAST. FIRST) <br />PHONEM WITH AREACODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COII4PLF..TFD) <br />NAME /'4 IC £ C S S <br />CD . <br />CARE OF ADDRESS INFORMATION <br />IIl..O 2 /CC6 <br />MAILING OR STREET A REBB <br />SUPVISOR-DISTRICT CODE -OPTIONAL <br />bubFdw!.3 ED INDIVIDUAL <br />0 LOCAL -AGENCY O STATE -AGENCY <br />X <br />,.✓/ <br />.02ORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CIN NAME �� � � <br />STMT - <br />ZIP CODE <br />PHONE I WI��EA C OE�� <br />III. TANK OWNER INFORMATI6N - (MUST BE COMPLETED) <br />NAME OF OWNER <br />G <br />CARE OF ADDRESS INFORMATION <br />IIl..O 2 /CC6 <br />MAILING OR STREET ADDRESS <br />SUPVISOR-DISTRICT CODE -OPTIONAL <br />✓ boxtokkala 0 WDMDUAL <br />O LOCAL -AGENCY 0 TATE-AGENCY <br />CORPORATION 0 PARTNERSHIP <br />O COUNTY -AGENCY OFEDERAL-AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE�WITH AREA CC DE <br />-'� <br />Cf <br />_ <br />IV. BOARD OF EOUALIZATI09(UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322.9669 if questions arise. <br />TY (TK) HO F4-74-- <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box 10 �tm 0 1 SELFWSUREO ED 2 GUARANTEE O 3 INSURANCE 0 A SUREIYBMD 0 5 LETTER OF CREDIT ED 8 EXEMPTION T STATE FUND <br />O8 STATE FUND BCHIEF FINANCIAL OFFICER LET TER OBSTATE FUND BCERTIFICATE OFDEPOSIT 010 LOCAL GOVT. MECHANISM 0 If <br />I <br />VI, LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is the ked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II. = III. Q <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 NAMEPRINTED& SIGNATURE) <br />TANK OWNER'S TITLE DATE MONTWDAYNEAP <br />IIl..O 2 /CC6 <br />/.�Ar <br />SUPVISOR-DISTRICT CODE -OPTIONAL <br />LOCACAdNCYUSE ONLY d ✓ <br />COUNTY Y <br />m <br />JURISDICTION Y FACILITY Y <br />LOCATION CODE - OPTIONAL <br />CENSUS TRACT Y - OPTIONAL <br />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 />FORMA (8-95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />