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�.. " iso ^ ea <br /> STATE OF CAUFORWA :� io <br /> STATE WATER RESOURCES CONTROL BOARD .e� n c <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ,. o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'t�•o."'' <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O ] PERMANENTLY <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> (:IiTNi PALO cuJ'Iv= 'Cktiouk" <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTI)NAL) <br /> 11-4111-A FLS ctT t��o 0V <br /> IZ <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> w <br /> co . t_ont CA 05Z.4(D <br /> TORN Box O CORPORATION CK INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY �COUNTY-AGENCY' �STATE-AGENCY• O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner of UST Is a public agency,corriolets the following:name of Supervisor of division,section,or office which operates the UST _ <br /> TYPE OF BUSINESS 1 GAS STATION ELI 2 DISTRIBUTOR pESEIF RVNDDION a OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS GP(r ocx:, I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREAE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11 P v Zcx1 _5V' +��5 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE S: NAME(LAST,FIRSTI PHONE%WITH AREA OCDE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box NIndicate 0 INDIVIDUAL LOCAL-AGENCYQSTATE-AGENCY <br /> Z'J� FF it IN• CORPORATION : D PARTNERSHIP COUNTYAGENCY FEOERAL#GENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1 wik Ga �f45n Iv S 7 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER, CARE OF ADDRESS INFORMATION <br /> `Icustp 4c-A0' <br /> MAILING OR STREET ADDRESS ✓ Eo ickwitNs INDIVIDUAL O LOCAL AGENCY 0 STATE AGENCY <br /> 'L%JtLO Cjt.),.(-.Lqv--teti� I�CORPORATION = PARTNERSHIP 0 CGUMAGENCY FEDERALAGENCV <br /> CITY NAME <br /> �/� STATE ZIP CODE PHONE#WITH AREA CODE <br /> AY{{7wce-L e14 44 �JI O TJoS-7Z�e <br /> IV.BOARD UALIZATION UST STORAGE F COUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) If6l 4 4 <br /> V. PETROLEUM AL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bYltlkaY 1 SELF-1 URED 0 2 GUARANTEE IZ 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT O a EXEMPTION I9 ag OTHER T-_ <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.[�] II.O IN. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 831GNE0) OWNER'S TITLE DATE MONTWDAV/YEAR <br /> ytx�Slc F�. ,�y LA ) o w� SlzzlgL <br /> LOCAL AGENCY USE ONLY <br /> COUNTY r JURISDICTION# FACILITY# ©07-A g 7 <br /> F71 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT T(1)OR MORE PERMIT APPLICATION- FORM Br UNLF- HIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOha..-.TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGRL-,ter.STORAGE TANK REGULATIONS <br /> FORM A(3'831 FORg(eIAA] <br />