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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD Cory <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> 1� COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY IG7r1/1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSFP SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> SS � <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> EMIL/5 LIQOoPS 3 hacKo amts <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> �9fl5 Cfl�LI� It ST. M�+1A/ ST Zz?- o7d -31 <br /> CITY NAME STATE <br /> ZIP COD S TE PH E#WITH AREA CODE <br /> 953Zo Zai 8 '6 <br /> ✓BOX CD CORPORATION INDIVIDUAL C3 PARTNERSHIP 0 LOCAL-AGENCY (]COUNTY-AGENCY' STATE.AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'low rol USTBopdseoagency,mmplets Nefonowbig:Nine of aper tof drcision,sxxxion oroNm which opetoes the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION Q 3 (AG 601 3318 3 FARM Q < PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> BOB ?�9 838- 683 <br /> NIGHTS: NAME(LAST,RR P ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> L\ 2-09 63b- -7683 <br /> If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> 30.8 Lf -xs>=- <br /> MAILING ORSTREET ADDRESS C ,x ✓ box to nckale >k'MDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> 7-5c>-7 Dt,JW 1 0 CORPORATION 0 'PARTNERSHIP E71 COum-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME O \ STATE ZIP CODE�32 T PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) /�Tc (TJ N <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Boa LeASf7 <br /> MAILING OR STREET ADDRESS ✓ boxb nSrale Q INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP a COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-T4--] 0 3 2 7 13 9 <br /> V. PETROLEUUM-- UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to iMimte Jm1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE (l 4 SURETY BOND O 5 LETTEROFCREDrT Q 6 EXEMPTION O 7 STATE FUND <br /> Q 8 STATE FUND B CHIEF FINANCIAL OFFICER LETTER Q9STATE FUND BCERTIFICATEOFDEPOSIT O 10 LOCAL GOVT.MECHANISM 099 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. IL[:] III. <br /> THIS FORM HAS BEENpGrETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRI ED8 IG TU E) TANKOWNER'S TITLE DATE MONTHVCAYNEAR <br /> c7 7 <br /> LOCAL AGENCY LN1554NLY "W <br /> COUNTY 11- JURISDICTION# FACILITY# O(� <br /> m : <br /> LOCATION CODE -OPTTONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> lv q <br /> THIS FORM MUST BE ACCOMPANIED BY ATL T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IN RMAT�N ONLY. <br /> �t <br /> OWNER MUST FILE THIS FORA1 THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO�TORAGE TANK REGULATIONS �'� I <br /> FORM A(6-75) <br />