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` 1 • • liWi l• <br /> STATE OF CALIFORMA o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION•FORM A <br /> COMPLETE THIS FORM FOR EACH ACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY C <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILTTYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA0 FACILITY NAME NAME FOPERATOR <br /> T LI PMCFI,IOPTKINAU <br /> ADDRESS NEARESTCROSS STREET <br /> STATE ZIP CODE S PHON WITH AREA CODE <br /> CITY E CA 2dy 982- X36" <br /> ✓ x CORPORATION INDIVIDUAL PARTNERSHIP LOCAL AGENCY COUNTY-AGENCYSTATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE <br /> DISTRICTS' <br /> N owner of UST Is a Public age .wmplae the following:nave of Supervisor of d"lon.section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN s OF TANKS AT SITE E.P.A. <br /> ❑ RESERVATION <br /> 3 FARM ❑ a PROCESSOR Q 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.FIRST) PHONE#WITH AREA CODE <br /> t Z- Iv3v <br /> NAME(LAST,FIRS <br /> PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIS: <br /> f <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMf,TION <br /> NA <br /> / ,/ box OlMltlb <br /> MAILING OR STREET ADDRESS Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME .STATE ZIP CODE PHONE#WITH ATEA CODE — <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA E FOWNER CARE OF ADDRESS INFORMATION <br /> AI LIN GORSTREETADDRajaESS ✓ ooXtomc9e Q INDIVIDUAL Q LOCALAGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL AGENCY <br /> Cl NAME STATE LP CODE PHONE#WITH AREA CO <br /> IV.B ARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ i»x to lydkae Q 1 SELF-INSURED Q Z GUARANTEE 0 3 INSURANCE Q d SURETY BONO <br /> Q 5 LETTEROFCREDIT Q 6 EXEMPTION Q g9 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.= II.❑ III.❑ <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 ONLY �tt <br /> COUNTY# JURISDICTION# FACILITY# 'tu"`9 / <br /> LOCATION CO -OPTfONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE,)NIFORMAATIONN ONLY.Yj' <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK EGULATIONS <br /> FOn6 <br /> FORMA(3/931 • �/�� J / ��� � ���f}(� �w✓ T07AF7 <br />