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I1—J PeS�•�.•.S CO <br /> i1/� STATE OF CALIFORNIA ,?• s <br /> Lw/ STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a���. �° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O 1 NEW PERMIT 0 3 RENEWAL PERMIT E�j 5HANGE OF INFORMATION O 7 PERMANENTLY CLO ED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME r NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> /vo �'tj©D C Q s <br /> CITY NAME11 STATE ZIP CODE TE PHONE#WITH AREA CODE <br /> A to cc, CA S 3 6 205 F�3-3'313 <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS E��l GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR [__:] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N E(LAS •FIRST) \ PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) Zc g 3S.a�So <br /> _ 010W-,; In�l S� Ff 2--5- 31513 M eo 0►^C a✓1 <br /> NIGHTS: AME(LAS ,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FI ST) <br /> �Ul ►n �0 -3--1 zS PHONE#WITH AREA nnnp <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> 4,nol-e e 74-o le <br /> MAILING OR ST EET ADD SS ✓ box to indicate = INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> i5vx ;�RPORATION = PARTNERSHIP 0 COUNTY-AGENCY E::] FEDERAL-AGENCY <br /> CITY NAMESTAR ZIP CODE CO 3O�/ PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SS wt. C� S <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - p Z `t 6� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 3 IN URANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 0 6 EXEMPTION 0 99 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: 1.0 II.�I.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY At JURISDICTION# FACILITY# F-U N K 13 <br /> m 10 011 JLJ 16 IV <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL G <br /> 32-6 .\0- (Z <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 /> FORM A(5-91) FOR0033A-5 <br />