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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3yd�, o 0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ;° <br /> MARKONLYI NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ T FERMAN TLY CLOSED. E <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' <br /> L <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D AOR FACILITY NAM NAME OF OPERATOR <br /> ADDRESS REST CROSS STREET PARCEL#(OPTIONAL) <br /> 4AQ D <br /> TV AME STATE ZIP CODE SITE PHONE k WITH AREA CODE <br /> O <br /> K�On CA CA 85215.1 <br /> 5215 C X31-2£ 0 <br /> \ .1IJ BOX CORPORATION 1] INDNIWAL PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY' STATE-AGENCY' O FEDERAL-AGENCY- <br /> TO INDICATE DISTRICTS <br /> #owner of USTkepubtica mmpletelhehmow g:name ol sgernwrol dwreon,section oroffice which operates Ne UST <br /> TYPE OF BUSINESS T GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.X(optional) <br /> RESERVATION <br /> ❑ 3 FARM ❑ A PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P ONE M WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> i ne a .I rn.e C ,�q — n t 9— c ?I Q._ <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODENIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> N ME CARE OF ADDRESS INFORMATION <br /> Tn1e 0. Q \T1l <br /> MAILING OR STREETDDRE,j21 ,(K� ✓ boxtomdcale 0INDIVIDUAL LOCALAGENCYElSTATE-AGENCY <br /> I CORPORATION [::] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> NAME CA ��n )r STATE Z�C�) PHONE#WI F EA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) hl J �(pY` `� <br /> E OF OWNER CARE OF ADDRESS INFORMATION <br /> - 2co ICknoe "N Y\ <br /> MAILING OR STREETADDR SS ✓/gwlo^O�a O INDMDUAL O LOCAL-AGENCY O STATE AGENCY <br /> `� dpLsQ CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> R WIS <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 U T FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> F�✓box to inWple 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O4 SURETYBOND 0 5 LETTEROFCREDIT O 6 EXEMPTION O T STATEFUND <br /> 1=wDESTATEFUND&CHIEFFINANCIALOFFICERLETTER OBSTATE FUND&CERTIFICATE OFDEPOSIT OTOLOCAL GOVT.MECHANISM 099 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: 1.[Rr 11.❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&'SIGNATURE) TANKK Whi i\S TITLE DATE MONNTHDAYNEAR <br /> 12_n <br /> T <br /> e ♦ x A 1 I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION <br /> # FACILITY# C' <br /> m <br /> LOCATION CODE -OPTIONAL 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 INFORMATION ONLY. <br /> FOR 95) OWNER MUST FILE THIS FO H THE LOCAL AGENCY IMPLEMENTING THE UNDERGRQ_- - "TORAGE TANK REGULATIONS <br />