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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> •� 'ter , <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE ' ' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED,SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACIL TY NAME . i�-%J j 7�f�//r_ NAME OF OP A7,R <br /> ADDRESS ,/ J N EST CROSS STR ET PARCEL#(OPTIONAL) <br /> q5,3 <br /> D�-J 3 y 9s e rte 1� �`f lew e-r'S /sz r- <br /> CITY 144YESTATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> rs✓ Tt cif CA Y,75- <br /> V, <br /> BOX Pt CORPORATION E�j INDIVIDUAL E] PARTNERSHIP E] LOCAL-AGENCY 0 CCUNTY-AGENCY' STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> II ownerof UST is a public agency,complete the following:name of supervisorof division,section or office which operates the UST <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR L__j ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS 4 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST, PHONE#WITH AREA CODE DAYS: NAME(LAST,PRST) PHONE#WITH AREA CODE <br /> �'' Q',Z ,Z — <br /> 1 <br /> NIGHTS: NAM (LAST,FIRS PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i"-v �c / GIO hes <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFI7I) <br /> NAME CARE OF ADDRESS INFORMATION <br /> r t�rC//Ie- <br /> MAILING R STRE ADDRESS r z '' 0 I*,'mvlcUnL LOCAL-AGENCY [] STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY•AGENCY [] FEDERAL-AGENCY <br /> CITY NAME STT E ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWIyER ` CARE OF ADDRESS INFORMATION <br /> MAILING ORSTREET ADD(+R']ESS / s ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> r � �Hu✓ �IQ(J, C []CORPORATION [] PARTNERSHIP COUNTY-AGENCY L] FEDERAL-AGENCY <br /> CITY NAM ST <br /> AATE 7JPCC�ODE PHONE <br /> j#WITHc�AREA CODE <br /> - 7713 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1SELF-INSURED 2 GUARANTEE I� 3 INSURANCE ®4 SURETY BOND E] 5 LETTER OF CREDIT [] 6 EXEMPTION � 7 STATE FUND <br /> 0 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 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 11 is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it.❑ III.,s1" <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERR`.',AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNf F 15 IIIAME(PPINTED•4,60 A IGlJAjURE) ! M'1 TANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# _ <br /> ❑ �❑ � �z/rte�� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY ATL ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORH THE LOCAL AGENCY IMPLEMENTING THE U'NDERGR*STORAGE TANK REGULATIONS <br />