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.... ."Not <br /> STATE OF CALIFORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD ?m�e :8 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A sw _ ,. ,: <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT r73 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION E::] ] PERMANENTLY CJASED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> yD +'4 <br /> ADDRESS NEAREST CROSS STREET PARCEL a(OPTIONAL) <br /> �3317 X.E7f44AW11t v6Z- 060-4119 <br /> CITY NAME STATE ZIP CODE SITE P ONE N WITH AREA CODE <br /> G vOr CA 9'l`-z-z-/v Opt, 33 <br /> ✓ BOX Q CORPORATION O INDIVIDUAL F-1 PARTNERSHIP LOCAL-AGENCY D COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL' Y' <br /> TO INDICATE DISTRICTS <br /> I sassrnl USTis apebk ago I,osmpss the laFowieg rendsq r&orof&aim,section or office while op,eales Na UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERINDIAN <br /> IAAN N OF TANKS AT SITE E.P.A. I.O.#(optimal) <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHgqNE�21TH9REACODvE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> bice /1�i / Zv�LJ �[Tf/ .77// <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFDI <br /> NAMECARE OF ADDRESS INFORMATION <br /> -Ti 1111. _r <br /> I -S�iEP d <br /> MAILING OR STREET ADDRESS ✓ NO,Ip CORPORATION <br /> O PARTNUALERSHIP <br /> LOCAL-AGENCY O FEOERSTATE-AGENCY <br /> O CORPORATION O PARINEASHIP I�COUNTY-AGENCY � FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> L ate- 95L v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Go D Ad T <br /> MNLING OR STREET AD RESS ✓ bos to Mimte 0 INDIVIDUAL O LOCAL-AGENCY DSTATE-AGENCY <br /> 3 O O CORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDEPA-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 2;Oft�- A 2 d <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓toaroieescse 0 1 SELF-INSURED =2 GUARANTEE 0 3INSURANCE 0 4 SURETY BOND O 5 LETTEROFCREDR =6 EXEMPTION E-1 7 STATEFUND <br /> 1�8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 1 18 LOCAL GOVT.MECHANISM O99 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.❑ it.❑ Ill.❑ <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 NAME(PRINTED&SIGNATURE) TANK OWNER'S TTLE DATE MONTA)AWYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® 2 7 r� <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0Z_ 25. �ZK <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 /> OWNER MUST FILE THIS FOFU THE LOCAL AGENCY IMPLEMENTING THE UNDERGRC\�STORAGE TANK REGULATIONS <br /> FORMA(6-95) T <br />