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• • <br /> STATE OF CALIFORNIA „��� <br /> STATE WATER RESOURCES CONTROL BOARD x d� °o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE N„ <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 ❑ a TEMPORARY SITE CLOSURE <br /> I. FA <br /> ��C <br /> IL <br /> ITY/SITE INFORMATION&��ADDRESS <br /> /--'(MUST BE COMPLETED) <br /> µ/'t[(e" AME-) •V UC/1/�^'�'✓`d �✓L✓ NAME OF OPERATOR <br /> ADDRE; f0"LN t{EAA �TFROSS EET PARCEL#(OPTIONAL) <br /> STATE1 41ZI 5ODE <br /> CA NE �EACODE <br /> CmE � z4ro <br /> ✓BOX 0 CORPORATION O INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY ED COUNTY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'IIamer of DSTIS NPIIbIG agency.=plate 1118 folbw4 IIBIIIBoISYPBNLorbcr.4iD1,SB[ nwotrKBWIkhoPoWa NIBUST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION FNDIAN N OFTANKS AT SITE E.P.A. <br /> ..P..A/� I.D..I t(optbMI) <br /> ❑ 3 FARM ❑ 4 PROCESSOR 'A 5 OTHER Oq TRUST LANDS Z CA'U qYo ✓�� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DY AME(LIIST.FIRST) PHON Y WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAEIni A, V B� CARE OF ADDRESS INFORMATION <br /> MILLLINGORS7$EETA�DRESS� 1, 61boat0h*Me ED INDINWAL LOCAL-AGENCY ED STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY ED FEDERAL-AGENCY <br /> CIT I fME I��A, ST!)TFy ZIP ODE PHONE N WGZE AAW ";?,Uv <br /> O,T <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) //dl S V <br /> NA E FOWN '\ CARE OF ADDRESS INFORMATION <br /> WI A • U <br /> M I NG OR SMI;ETADDJRESS .7 ✓ boxbff6mlY O INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> {� D CORPORATION D PARTNERSHIP O COUNTY-AGENCY E:1 FEDERAL-AGENCY <br /> CI N ME Sr�TE ZIP OOE HONE N WITH AREA CODE <br /> Dint �fA c �ts33b ?�� kzc-3ztD <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 /> ✓boBbndioatN 0 1 SELF-INSURED2 GUARANTEE ED INSURANCE E-14 SUPETYBOND ED 5 LETIENOFCRmn 0 6 EXEMPTION B9STATE FUND <br /> D 8 STATE RIND&CHEFFINANCIAL OFFICER LETTER O9 STATE FUND&CERTIFICATE OF DEPOSIT Oto LOCAL GOVT.MECHANISM OOT7 HER <br /> VI. LEGAL NOTIFICATION AND BI ING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 its checked. <br /> CHECK ONE BOX INDICATING WHICH ABOV DDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[::] II.M III.❑ <br /> THIS FORM HAS BEEN CO ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> 'S NAME(PRINTED R N T K O,^W�N..E/IR�''S / GATE D rMONTHI A�AR <br /> QCk ittiiY �� <br /> LOCAL AGENCY USE ON <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <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 /> OWNER MUST FILE THIS FORM*THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWTORAGE TANK REGULATIONS <br /> FORMA(6.95) <br />