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9 0 t't60UA -4 C <br /> STATE OF CALIFORNIA �� a <br /> STATE WATER RESOURCES CONTROL BOARD mom, n?o° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °•�„a N, <br /> MARK ONLY F__] t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> SPA OR FACILITY NAME NAME OF OPERATOR <br /> Ili a?,E5 ✓akir'A,=. -a-,M ✓� Pv� <br /> ADDRESS NEAREST CROSSTRE�EET PARCEL#(OPTIONAL) <br /> UV 1✓! tF ---aj /Si--> <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> La� CA �t�7-40 <br /> ✓ BOX <br /> TO INDICATE 0 CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' <br /> DISTRICTS' FEDERAL-AGENCY' <br /> If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS F--j 1 GAS STATION F__] 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR E=] 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 /> Vi5 —56A-75 T/ v ) 369—7 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AR A CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> P f 4"e15— <br /> MAILING <br /> "e15/� I/El�Tv�2� <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ,�)7--) w, L-a�� / CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> i 0ITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> t 1,(,,C r C+ 9'_6-Z-q <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box toindicale INDIVIDUAL 0 LOCAL-AGENCY E71 STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY E�] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4t74- -=�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box IDindicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 5 LETTEROFCREDIT 6 EXEMPTION 0 99 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 II.E:1 IIIA <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 8 SIGNED) OWNER'S TITLE DATE MONTH/DAYNE-AR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILfTY#067-3-3 7 <br /> -[�K1 m I I I I I D a <br /> 3.3Z <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 3`w a) (", <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF fin INFIDR ON ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) . � FGR6033A-R7 <br />