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//ll / �,j a <br /> STATEOFCAUFORMA Q/F/ (p 10 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A COMPLETE THIS FORM FOR EACH FACILRYISITE ��yy <br /> MARK ONLY � I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY ITE <br /> ONE REM r7 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DPAOR FACILITY NAME /J <br /> NAME OF OPERATOR <br /> VmAwr /MJc Che - a_Jk <br /> ADDRESS NEAREST CROSS STREET PARCELP(OPTONALI <br /> 4c�0 � &, <br /> I-S, <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> FA4(y CA <br /> v Box <br /> T NDCATE ®CORPORATION O INDIVIDUAL =PARTNERSHIP O LOCAL-AGENCY 1=1 COUNTYAGENCY• ED STATE-AGENCY' O FFDERALAGENCY• <br /> DISTRICTS. <br /> N owner of UST Is a pubic agency,complete the folowing:name of Supervisor of oivbbn,section,or office which operates the UST <br /> TYPE OF BUSINESS P<1 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN Is OF TANKS AT SITE E.P.A I.D.i(optAawl) <br /> = RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 6 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH <br /> 04 4/2/- �dll!gog 95, (16'3 AREA CODE <br /> NIGHTS: NAME iVST,FIRST) PHONE i WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> MAIi K I,,tE 6tx/- 6�SI <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME ® CARE OF ADDRESS INFORMATION <br /> CN TREV7 ALUA IMC. Nimbi <br /> MAILING OR ST`R�EET ADDRESS ✓6a bNdkaN INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> Xj CORPORATION O PARTNERSHIP COUNTYAGENCY � FEDEMLAGENCY <br /> aTM0� �0 sTATI,- ZIP OODEPHONE f 31 WITH AREA CODE <br /> �7i7�I�S3 <br /> [4 <br /> III.. TANK OWNER INFORMATION-(MUST BE COMPLETED) L� <br /> NAME,OFOWNER A CAREOFADDRESS 1NFO INFORMATION <br /> MAILING OR STREET ADDRESS .1 <br /> buloveso s = INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 4W /O� a--("A�C+K- /O/L- a 24rCORPDRATION O PARTNERSHIP =COUNTY AGENCY FEDEML-AGEWY <br /> CITY E $TATE ZIP C�qDE HONE i WITH AREA CODE <br /> 018�-T'6 (ak 1 C'77 8 '06107) <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4T4_+ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to ndkaht 0 1 SELF-INSURED 2 GUARANTEE O 3 INSURANCE A SURETY BOND <br /> O 5 LETTER OF CREDIT O 6 EXEMPTION Q 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: 1.O IILr III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHrOAYNEAR <br /> etAW LIZ,Dj 4z 1. P94?; (t6FW_T d}'- /2—97 <br /> LOCAL AGENCY USE ONLY L�E <br /> COUNTY a JURISDICTION a FACILITY a <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> aS <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INIFOROATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(399) FORMY497 497 <br />