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t u �t <br /> CV60VP ; C <br /> STATEOFCAUPORMA :� li <br /> STATE WATER RESOURCES CONTROL BOARD W m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A :- , �s <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `'��.ea+`' <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT F-1 4 AMENDED PEflMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAORFACILITYNAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELO(OPTIONAU <br /> CITY NAME 1STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> A n -T'ec CA <br /> TO INDICATE ATE 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY, O DISTRICTS' STATE-AGENCYFEDERAL-AGENCY' <br /> N oxner of UST Is a public agency,complete the following:name of Supervisor of di isbn,section,or office which operates the UST <br /> TYPE OF BUSINESS fY'1 1 GAS STATION Q 2 DISTRIBUTOR IFINIONIAN #OF�ATSITE E.P.A. LD.aloptlarre) <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE R WITH AREA CODE <br /> e'AMA,L- q -,,=A4.OZ6 <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> sw,n,� a13o E <br /> iMP <br /> ROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> yoos F oyii-S <br /> MAILING OR STREET ADDRE S ✓EwbinCRab NDIVIDUAL OLOCAL-AGENCY OSTATE-AGENCY <br /> Pe— DCORPORATION O PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY N ME STATE ZIP CODE Zr4 8 WI AQR ODE <br /> OOHS�S/C-A6 l <br /> ANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Ff? t kosft4cV� <br /> MAILING OR STREET ADDRESS (n� ✓ box to indicate u INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> CORPORATION PARTNERSHIP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CRY NME STATE ZIP COg E PHONE a WITH AREA CODE <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 UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bot bIndicate 0 1 SELF-INSURED 0 2 GUARANTEE = 3 INSURANCE 0 A�17RETY BOND <br /> O 5 LETTEROFCREDIT O 6 EXEMPTION fX go OTHER U A tl <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.= II.� Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED B SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR <br /> ays .lti}S 1 1 2-zl-71 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# � �i/ <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL 9UPVISOft-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 FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOflM�3A13) FOR0033AA7 <br />