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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD i dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE In <br /> MARK ONLY ® 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION T PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 0 AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA R FAC I�j;;;CA 7 Q Ieven � I���_7 NAME OF OPERATOR <br /> ADDRESS {I^�^N•' L.• l/ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> osemr�e Ave. EI Portal Ave. <br /> CITY NAME , TA <br /> STE ZIP CODE SITE PHONE#WITH AREA CODE <br /> arlteca CA 53 <br /> ✓ BOX CORPORATION O INDIVIDUAL Q PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' = FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'Nownerof UST isepublkaprey,oxnplelelbe following we of upervisord division,section moffioe Oa opeaes the UST <br /> TYPE OF BUSINESS ® t GAS STATION Q 2 DISTRIBUTOR Q ✓IF INDIAN #OFTANKS AT SITE E.P.A. I.D.#(optioneo <br /> RESERVATION <br /> Q 3 FARM Q # PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FI T) PH NE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> - I 01n)463--4-711 <br /> NIGHTS: AM (LAST,FIRST) PH E#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1) t 25 4'(03- z-71 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF AD RESS INF RMATION <br /> v *inJ c xo iai oip <br /> MAILINGOR STREET ADDRESS ✓s box to hxirale INDIVIDUAL EDLOCAL-AGENCYOSTATE-AGENCY <br /> I? 1�1( 711 W CORPORATION Q PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAM STATE ZIP CODE PHONE p ITH AREA CODE <br /> 75ZZ1 -0-711 (�Z5 4�3- Z711 <br /> III, TANK OWNER INFORMATION.-(MUST BE COMPLETED) <br /> N E OF?VNERm v: r CARE OF ADQRESS INFORMIYTION O <br /> ,U,.{)-LCL 1Y_d ,.-1F yv7av 11•`#1 inn <br /> UNG OR STREET ADDRESS .1boxtoiNhate Q INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> VO. 77CX -711 TVI CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> II aS T.X. 75Z2,11 -OZ I Z5 2 Z25 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ M44- D D E 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box 0 bGmfe I=1 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE =#SURETY BOND 99 5 LETTER OF CREDIT =&EXEMPTION O T STATE FUND <br /> O B STATE RIND&CHIEF FINANCIAL OFFICER LETTER (]#STATE RIND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM = ##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.Ej II.0 III.i5 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> mOWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE <br /> /T,,ly�� DATE MONTH/DAYNEAR <br /> r +/I7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Op 0 e08' <br /> m 3 / 4W <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 /> FORMA(s-ss) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />