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STATE OF CALIFORNIAO`v <br /> STATE WATER RESOURCES CONTROL BOARD ice' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A `^ <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE3`�3 <br /> MARK ONLY �1 NEW PERMIT F73 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED.SITE I, <br /> ONE ITEM Ej 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) pp d <br /> DBA OR FACILITY —NAME NAME nRATOR I <br /> SA ���• <br /> Q FU LFY. 'I F NTC JCC //1--\�s �' <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> Ali <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> C�LZO tJ CA <br /> ✓BOX E CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY- O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> #owneral UST is a public agency,=plele the lollowng rem°al swarmsoral d",xi,section craft which apendes Na UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR O ✓IF INDIAN #OFTANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N E(LAST,FIRST) PHO E M WITH A5E�A CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> A I �a'L'- � 52-Z-,-20 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION-(MUST BE COAAPLFTFO) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILINGO STIR ET ADDRESS ✓/st0r `c Q INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> S f b f.1�� t IJCl L G-" M CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAM STATE ZI O E G P NES(,WITH AREA CODE <br /> 7�SAt C a �702'S V2 —4(P 7- ZO(.k <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER,����A CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDR SS /' ' /II #1�/ ✓ to ndx2le O INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> ( N E--tD L 1—'n"ti , `n CORPORATION Q PARTNERSHIP =1 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME 5T ZIP OD HONE#WITH�R/E.A CODE <br /> P 0 'ss-6 25--�-7- zOi#P <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 FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> Ez✓bosbindiCateEFJ 1 SELF-INSURED Q 2 GUARANTEE O 3INSURANCE =4 SURETY BOND 5 LETTER OF CREDIT Q 6 EXEMPTION =7 STATE FUND <br /> 7ww #STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09STATE FUND&CERTIFICATE OF DEPOSIT O10 LOCAL GOVT.MECHANISM O99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. <br /> CH E ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.O III. <br /> S FORM HA61 <br /> EN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> ANK E A (PRI E SIGNATURE) 5 94/ TANK OWNER'S TITLE DATE MONTHYDAW/YEAR <br /> CplD •�elis 60 SLLL-r#AJj OvL /D <br /> LOCAL AGENCY USE ONLY <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 WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(6-95) <br />