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C60VR C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD F n� Ac <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE Cil PORN' <br /> MARK ONLY t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O F LITY NAME NAME OF OPERATOR <br /> CIV <br /> ADDRESS NE EST CROSS STREET PARCEL#(OPTIONAL) <br /> Cly NAME STACA ZIP�2-gz-/ SITE _ Lk0C13 <br /> ON WI AREA CODE <br /> I/ BOX <br /> TO INDICATE O CORPORATION Q INDIVIDUAL PARTNERSHIP LOCAL-AGENCY (] COUNTY-AGENCYE=1 STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST Is a public ag!n$V,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR a ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> 45 NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREACODE <br /> s '� G —O S� 3 -c� <br /> JfiHT : NAME(LAST, I ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> -3 -q7q— <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME R'VWSVz2 B4 CARE OF ADDRESS INFORMATION <br /> G <br /> MAILING OR STREET ADDRESS ✓box Io Indicate � INDI AL = LOCAL-AGENCY STATE-AGENCY <br /> ICAW 7714- '- v'i 0 CORPORATION ARTNERSHIP = COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> Its TY OAME s STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER (� CARE OF ADDRESS INFORMATION <br /> V-1 - <br /> MAILING OR STREET ADDRESS ✓ box to indicate [=1 INDIV 0 LOCAL-AGENCY E�:]STATE-AGENCY <br /> CORPORATION ARTNERSHIP 0 COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME I STATE ZIP CODE PHONE#WITH APEA CODE <br /> Sam <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4--]- <br /> V. PETROLEUM UST FINANCI ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b indicate 1 SELF-INSURED /O 000 o 0 2 GUARANTEE INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 6 EXEMPTION �99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless W or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> M <br /> AME R ED rED <br /> OWNER'S TITLE ^ DATE ONT DA <br /> i � <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY;# <br /> ! 4l <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 9UPVISOR-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(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATHM <br /> 3A fl7 <br />