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STATE OF CALIFORNIA J�` <br /> STATE WATER RESOURCES CONTROL BOARD 3.,� o�; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A :@ <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION a 7 PERMANENTLY CL <br /> ONE ITEM 0 2 INTERIM PERMIT (J—I d AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> �HEyRoN s— o r - I8 aoE�_= N A4 t✓I <br /> ADDRESS <br /> NEAREST CROSS STREET PARCELF(OPTIONAL) <br /> 125-7 � • `(OSEM ITS AJC <br /> CITY NAME STATE ZIP CODE SITE PHONE M WITH AREA CODE <br /> ��p� CA 533 209- 23- • S-4_ <br /> ✓BOX CORPORATION INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY O COUNTYAGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> TD INDICATE DISTRICTS <br /> 'No arol USTeaPubksgvq.=PNla Nelolb hW romedsu mmr d 6wision,section ordfce wh hoDeno.the UST <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR RESEIRVATIION NOF TANKS AT SITE E.P.A. I.D.#(oplbnap//a / //– <br /> 3 FARM Q d PROCESSOR Q 5 OTHER OR TRUST LANDS G,4L_0coo 291o�A0 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) �PHONE#WWITHH AREA Co <br /> CDANYS: NAME(LAST,FIRST) LL PHONE#WITH AREA Cj Z o <br /> NIGHTS: NAME(WAST,FIRST) EE oNE^.""'H AREA CODE NIGHTS- NAME�LABT.EINGT)���µ�� PHONE M WITH AREA CODE S <br /> A,AMeP A DEE 5l0 7S�} !0231 CHEM) E 506GAV -Y )Aw. 8m•231 c�23 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> �HE v�orl P�u�-Ts c�a�nP�Y <br /> MAILING OR STREET ADDRESS ✓ bo#te nd#ale = INDIVIDUAL = LOCA-AGEWY OSTATE-AGENCY <br /> • CORPORATION O PARTNERSHIP l= COUNTY AGENCY FEDERAL-AGENCY <br /> CITY NAME t!J STATE ZIP CODE PHONE x WITH AREA CODE <br /> -e �AMoN GA s83 -8 Z- 1,202 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) 6.1 ZS) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> � �V +J f;oDU�- 5 �'vM A3v� MtT D�sK <br /> MAILING OR STREET ADDRESS ✓ bo#to intl#Ele Q INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> CORPORATION PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME WSTATE 21P CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise.MZT <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓bo#N inSrate �!I SELF-INSURED O 2 GUARANTEE =3 INSURANCE O d SURETYBOND O 5 LETTEROFCREDIT =6 EXEMPTION L_J 7 STATE FUND <br /> f�a STATE FUND&CHIEF FINANCIALOFFICERLETTER O 9 STATE FUNDSCERnFICATEOFDEPOSIT = 10 LOCAL GOVT.MECHANISM = 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.❑ II.D 111.0 1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK O NEB'S NAME , IMTED,&SIGNA <br /> TANK OWNERS DAM NTWDAYNEAR <br /> l/L'—/OCALAGENNACY IUSEOJ ONLY <br /> rl #J 7^f 8 <br /> COUNTY M JURISDICTION# FACILITY M <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -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 /> OWNER MUST FILE THIS FOR,�'H THE LOCAL AGENCY IMPLEMENTING THE UNDERGR( STORAGE TANK REGULATIONS <br /> FORMA(6-95) 1-W <br />