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*taou..es c <br /> STATE OF CALIFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s a= <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE I� <br /> MARK ONLY t NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION EJ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1, FACILITY/SITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITYAME �� NAME OF OPERATOR/ L L C <br /> CC//77 D <br /> ADDRESS NEAREST CROSS STREET PARCEL p(OPTIONAL) <br /> 41CITE I r t 1E. �C �L n� ' LfJ. ► I P-D, 141 <br /> CITY <br /> Y NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 1,0D f CA CISZ4a <br /> ✓BOX F-1 CORPORATION © INDIVIDUAL E4 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> II owner of UST is a public agency,Complete the following:name of supervisor of division,Section or office which operates the LIST <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR <br /> RESERVATION <br /> AN TYPE #OF TANKS AT SITE E.P.A. I.D.N{optional) <br /> Q 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE H WI H AREA CODE DAYS: NAME(LAST,FIRST) P NE M WITH AREA CODE <br /> C� Li� 5P( L Zo" I n3 5i"0R� ©Br=-P ZOq 7fS�-5616 <br /> NIGHTS: NAME(LAST,FIRST) PHONE q TH AREA CODE NIGHTS: NAME(LAST,FIRST) HONE#WITH AREA CODE <br /> &Iues1?f� ALF 709 22 <br /> 3R- 3ANDfk4 0e)E+2LE z-DG5 3f5-S�nI <br /> IL PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATIO <br /> MAILING OR STREET ADDRESS ✓ boa to indcate 0 INDIVIDUAL =LOCAL-AGENCY STATE-AGENCY <br /> TAY dx fl Q CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAL_O STATE ZIP COD ��I PHONE ri WITH AREA CODE <br /> G917 <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> SSMr✓ �� ��- <br /> MAILING OR STREET ADDRESS V boa to ndicafe INDIVIDUAL = LOCAL-AGENCY 0 STATE-AGENCY <br /> 0 CORPORATION C] PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 p-1 C>13 18 -2- -2— <br /> V. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> boa to indicate tSELF-INSURED 2 GUARANTEE 3 INSURANCE [] 4 SURETY BOND �S LETTER OF CREDIT I�6 EXEMPTION 7 STATE FUND <br /> (] B STATE FUND&CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND&CERTIFICATE OF DEPOSIT 10 LOGAL GOVT.MECHANISM 48 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-= 11.X III.O <br /> !S FOA AS BEEN COMPL ETED CINDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK W R'S AME(PRINTED&SIGNATURE) _ TANK OWNER'S TITLE DATE THIDAYNEAR <br /> Wl <br /> LOCAL AGeNC4 USE ONLY <br /> COUNTY N JURISDICTION# FACILITY# <br /> rd 0 <br /> m L � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL 1 ` <br /> THIS FORM MUST BE ACCOMPANIED BY ATT(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO*TORAGE TANK REGULATIONS <br /> FORMA(6-95) <br />