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STATE OF CALIFORNIA �,,,e.���e <br /> 00 <br /> STATE WATER RESOURCES CONTROL BOARD u d� °a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s - <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE.' - , le <br /> MARK ONLY OZ-1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ;�;Ej T PERMANENTLY CLOSED.SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR��, <br /> ADDRESS / NEAREST CROSS STR T PARCEL#(OPnONAL) <br /> 50 a3 N �2 £ �` /7'A7 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> .,j .J CA 17SL3 8V7,3000 <br /> ✓ BOX E—)CORPORATION INDIVIDUAL O PARTNERSHIP O LOCAL-AGENCY 0 COUNTY-AGENCY' Q STATE-AGENCY' D FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 9 oweral UST La a public agency,a mplele the l01b.09.twee of supervisor d division,section ora#be efiich wetsles the UST <br /> TYPE OF BUSINESS ❑ T GAS STATION ❑ 2 DISTRIBUTORREV IF INTDIAN ION #OFTANN�KS AT SITE EE./.+PP�.A..�I.D.#(optional) <br /> ❑ 3 FARM ❑ 4 PROCESSOR � 5 OTHER OR TRUST LANDS t� (,1j(i QZ/G t <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRSTL� PHONE#WITH ARE CODE �� DAYS: NAME(LAST,FIRST) <br /> : PHONE p WITH AREA CODE <br /> NIGHT NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFO) <br /> NAME o! LZ 1J CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET DDRESS / ✓ bcxton'_ 3 _n� NDIVIDUAL O LOCAL-AGENCY 11 STATE-AGENCY <br /> —J(� Z LP/arCORPORATION O PARTNERSHIP COUNTY-AGENCY =1 FEDERAL-AGENCY <br /> CITY NA Fes, O BTA ZIP C DE O PHONE#WITH AREA CODE72 <br /> aj <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) S G <br /> NAME OF OWNE I� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADD GRE/S�S/ / jam` V' Mxlomdicale -�DIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> —/ 2- 4 r (. �/�/L l�CORPORATION O PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME ST/�I ? ZIP CODE PHONE#WITH ARE/yC DE���� <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-L--Call(916)322.9669 if questions arise. 7/� <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to IMcale SELF-INSURED O 2 GUARANTEE O 3INSURANCE O 4 SURETY BOND lI 5 LETTEROFCREDIT O 6 EXEMPTION L_j]STATE FUND (r <br /> O8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER O9STATE FUND&CERTIFICATE OFDEPOSIT I� SIIILOCALGOVT.MECHANISM = 99OTHEfl ' <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.❑ 11.1o� III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL OF tRJURI,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> i5,4z Lv �l,JS t <br /> LOCAL AGANCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> � 3 <br /> LOCATION CODE-OPTIONAL CENSUS TCT#_,OfiT/ONAL SUPVISO©DD T COj)E -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST T((✓1)lOR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIO 0 YJ <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS 2 NO O <br /> FORM A(6-95) <br /> < ,� <br />