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STATE OF CALIFORNIA c#5+ <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION . FORM A , <br /> 18 <br /> COMPLETE THIS FORM FOR,EACHFA ITE„ <br /> 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INF BMA.T♦BtY!0 T PERMANENTLY C405ED SITE <br /> MARK ONLY I <br /> ONE TEM � 2 INTERIM PERMIT 0 < AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERALOn�f e S1O INC, <br /> AP C O �C Ac . 1033 S S ST \ PARCEL.(OPTIONAL) <br /> ADDRESS <br /> ADDRESS I <br /> EST CROSS STREET <br /> 4455 Snake !\w �t°t vorr�ave Ra <br /> CITY NAME CA ZIP CODE SI/ZOTE PlIDNga ITN Rr3r <br /> O�I\\1I P <br /> ✓BOX PkCORPORATION 0 INDIVIDUAL F-1 PARTNERSHIP C3 L�•AGENCY OCOUNTY-AGENCY' CD STATE-AGENCY' OFEDERAL-AGENCY' <br /> TO INDICATE <br /> CTS <br /> r d su9eNtwoIdnebn,s#d'onvW=*Ie MOON"UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR 0 RESEIRVATION F INDIAN NOF TANKS AT SITE E.P.A I.D.N(optional) <br /> Q 3 FARM O a PROCESSOR Q S OTHER OR TRUST LANDS <br /> ----EMEAGENGY-GONiAGT-PERSON{PRIMAR ENCY-60NFAC7PERSON <br /> DAYS: NAME(LAST,FIRST) PrON #WITH AREA CODE DAYS: NAME LAST,FIRgT) PHONE WITH AREA CODE <br /> UP, m 1JvT l >�1�a�8-2 34 �rco {OlA\v e4c X800 212-b3a°1 <br /> NIGHTS: NAME(LAST.FIRST) PON #WITH AREA CODE NIGHTS: NAME(UST.FIRST) ,L PHONE N WITH AREA CODE <br /> f� aN 1;z, � �a�� aa3� <br /> OWNER INFOR ATION•(MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Raco Q�a� cc) . atk 6 S <br /> MAILING OR STREET DRESS (� ✓ wxb^d� NDIVIOUAL O LOCAL-AGENCY a STATE-AGENCY <br /> CORPORATION PARTNERSHIP ED COUNTY-AGENCY =1 FEDERAL-AGENCY <br /> CITY NAME r� STATE ZIP CODE PMO E N TH AREACODE <br /> �1J �esA�1 CIO Qo1o2—l�o3S �tvb�o-S�o <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER ((�� \\ � CARE OF ADDRESS INFOR ATION <br /> RCC9 <br /> MAILING OR STREET p.-pF��KESS ✓ tv tonEsala Q INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> V, O ,bc,f{ 0/� O CORPORATION E3 PARTNERSHIP O COUNTY-AGENCY ED FEDERAL-AGENCY <br /> CITY NAME \ -n ST UP CODE PHONE# TH AREA CODE <br /> s t � rl` S A2^(_03 C� 4EACOD �D <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F474- - <br /> 6 6 5 0 lD <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓oosb iMbl# 1 SELF-INSURED O 2 GUARANTEE O 3 INSURANCE O a SURETY BOND O 5 LETTEROFCREDR El 6 EXEMPTION O T STATE FUND <br /> a STATE FUND&CHIEF FINANCIAL OFFICER LETTER E39 STATE FUND&CERTIFICATE OF DEPOSIT ED 10 LOCAL GOVT.MECHANISM E399 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: L Il II.O <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TT <br /> TANK WA�R'S NAME(PRINTE0851GNATURE) EAR <br /> TANK OWNER'S TITLE nn \� DATE MpNT AY; <br /> 177, ,, 3, . �1 — f t rl . �tawea M M\N, 3 61 3$ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY p <br /> -3136 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3•�io <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERM(T APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR `N'Tf?b+H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO' STORAGE TANK REGULATIONS <br /> FORM A(695) <br /> Zb . « L Soac{�Yv .E -o . 388 $f cKTDnI CA. G S20\-dW <br />