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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE `'��•ae+" <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O ] PERMANENTLY CLOSED SITEa�'�� <br /> ONE REM ] 2 INTERIM PERMIT 1 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE ( l U <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEOFO ERATOR <br /> $OU 150L)—f'E1t�flp <br /> ADDRESS'_ 43 G. 5-1ATG 4.-, n STREET PMCELaIOPfpNAu <br /> v`�.Za ci� Aazo I' G <br /> CITY NAME ~ STATE ZIP COPE SITE PHONE 0 WITH AREA CODE <br /> L� CA ry'' No-r AvA)LAi L.L:. <br /> ✓ BOX �CORPORAT10N O INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' a STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> H owner of UST Is a public agency,complete the following:name of Supervisor of d"ion,section,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION O 2 DISTRIBUTOR O ✓ IF INDIAN 1*OF TANKS AT SITE I E.P.A. I.D.0 Topfimmo <br /> O RESERVATION <br /> 3 FARM O 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIR9IT) PHONE N WITH AREA CODE <br /> L�WI IRJIy 'DrIU 17 )1 51u-41o3—Z"t1i <br /> NIGHTS: NAME(L T,FIRST) PHONE#WITH AREA CODE NIGHTS: NAM (LAITT.FIRS PHONE#WITH AREA CODE <br /> L.ks Ili l�i IS A.Jir SIU- 4(1-?-2"111 0 _ Ali 5�0-4�3-2'111 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME Gmqo' H PD �Y CARE OF ADORE S$aI;F�RMATJQN 4 <br /> MAI NG'O^R STR T ADDRESS 1/•.�f L_ n ✓ bot Wmicate /� 4 j INDIVIDUAL Q LOCAL AGENCY I� STATE AGENCY <br /> 99 C1V A ?T-D �CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NT <br /> ESTATE ZIP CODE PHONE#WITH AREA CODE <br /> fit✓ [A� °IQSrd$ SIO- �3-Z"71� <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOF OWNER CARE OF ADDRESS IN MATION <br /> hi OR STRE TADDRESS �j ✓ box b indicate I7 INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY <br /> '2D 5 (J e: HA 40 <br /> 3If ED CORPORATION O PARTNERSHIP O COUNTY AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATEZIP ODE PHONE WITH AREA CODE <br /> .JTUN l-ws_a8 1 1510-4b3-zj l l <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boa b Indicate 0 t SELF INSURED 2 GUARANTEE 'M 3 INSURANCE [7:14 SURETY BOND <br /> 0 5 LETrEROFCREDIT 6 EXEMPTION 0 MI 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.D Imm III.O <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&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONL <br /> COUNTY# ^ JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT�(1)OR MORE PERMIT APPLICATION• FORM B,UNLEMIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO TORAGE TANK REGULATIONS <br /> FORMA(G53) - F0110D13AA7 <br />