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STATE OF CALIFORNIA .°, O\171 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY �1 NEW PERMIT F73 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SfTE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) 0 t)D C( bq <br /> DBA OR FACILITY NAME NAME OF C ERATORV�py ��L <br /> :S = A rte- �> Nr JC A <br /> ADDRESSNEAREST CROSS STREET PARCEL/(OPTIONAL) <br /> 'paurtc, bE <br /> CITY NAME t STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> G�(-�/ N CA <br /> 61 Box C ,'CORPORATION [:3 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> O o.v of UST is a DubTz;agenry,mnplete Ne lolbwng Mame d s�Pervisard drvksectiona x11 <br /> n,sen or oHcLi1 operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(opllwap <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N ME(LAST,FIRST) PHO E M WITH ZCODE DAYS: NAME(LAST,FIRST) PHONE A,WITH AREA CODE <br /> 1 �tl:�Sls- 25- `1-Zd4� <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ESQ l (✓ <br /> MAILING OR STR ET ADDRESSN1 O NOtViDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 4 1 S W'wII J <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME S Q� STATE ZlgfQE, O� F'MO?E�WITH AR COO�O r� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) l�`, `{ `✓ rT/(� LQO�F <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SAreIl.Ia � (✓• <br /> MAILING OR STREET ADDRESS �� ✓ Cy fo ndiala Q INDIVIDUAL O LOCAL-AGENCY ED STATE-AGENCY <br /> I �CE l tD('l. Rn I„J/CORPORATION =PARTNERSHIP (]COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CIN NAME TN� S rA <br /> A�� \ ST ZIP/600kGS5� HONE#WITH AREACODE <br /> IV. BOARD OF EQUALIZATION <br /> UST STORAGE FEE ACCOUNT NUMBER-Call(9164)'322-9669 if questions arise. �FLJy LV <br /> TY(TK) HO 744--]- <br /> V. PETROLEUM FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Ooz to ind'rate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION L:17 STATEFUND <br /> F�­ ­ <br /> OS,STATE FUND&CHIEF FINANCIAL OFFICER LETTER 09 STATE FUNDS,CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM 1099 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 /> CHE ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.❑ II.❑ III. <br /> S FORM HA BEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> ANK E A (PRIN E SIGNATURE) XeLFCN+/" N TANK OWNER'S TITLE DATE MONTWDAwYEAR <br /> A,I o L S��)S GuNsaLraA.) (7u Ah (-D� <br /> LOCAL AGENCY USE ONLY LL <br /> COUNTY# JURISDICTION 8 FACILITY <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANn �Q <br /> -TOOWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TI O rJt- .to/ 1,- <br /> FORMA(695) L l <br />