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0 • <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A <br /> i COMPLETE THIS FORM FOR EACH FACILITY/SITE r-� <br /> MARK ONLY El NEW PERMIT ❑ 3 RENEWAL PERMIT E] 5 CHANGE OF INFORMATION yr T PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE T <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 7-11 ✓ XvJ�L NAME OF OPERATQR <br /> So2Cdr , r <br /> r' N EST CROSS SS TREET IPARCEL (OPTIONAL) <br /> ADDRESS 1 <br /> T53 4 CITY N ME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA - <br /> .130 .M CORPORATION 0 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> Il ownerof UST is a publlo agency,wMime the following:name d supelvsorof dMsion,section oroNce which operates the UST <br /> TYPE OF BUSINESS fVl I GAS STATION O 2 DISTRIBUTOR ❑ RESEIRVATION #OF TANKS AT SITE E.P.A. I.D.#(Wtianaq <br /> ❑ 3 FARM Q 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS Tl PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAM (LAST,FIIRR</SL!~ PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> d5- vv & <br /> IL PROPERTY OWNER INFORMATION-(MUST BE COA11PLETFD1 <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> (LG <br /> MAILING RSTAEET&RESS ✓ �`1Jo'"��' OIKOIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP E3 COUNTY-AGENCY E:1 FEDERAL-AGENCY <br /> STI�TE ZIP CODE PHONE#WITH AREA CODE <br /> CITU NAME Crrl . <br /> t Dw/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOW R CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS y .1boxtolodMmte ED INDIVIDUAL EDLOCAL-AGENCYD STATE-AGENCY <br /> S W S.1 Q CORPORATION O PARTNERSHIP Q COUNTY-AGENCY = FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAM <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ KK_ <br /> -CZ� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> 61 box to indicate 1 SELF-INSURED � 2 GUARANTEE 0 3 INSURANCE (] d SURELY BOND ED 5 LETTEROFCREDIT O 6 EXEMPTION 0 T STATE FUND <br /> Q ESTATE FUND&CHIEF FINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT 010 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.❑ 111.-r <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANKOWN ME(P INTED IGNA RE) r N1 a TANK OWNERS TITLE DATE MONTWDAYNEAR <br /> sdT 74�� or,I.. —9 <br /> LOCAL AGENCY SE 6NLY <br /> COUNTY# JURISDICTION# FACILITY# / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL /Z '/ ( J <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*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROOTORAGE TANK REGULATIONS <br /> FORMA(6-95) <br />