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t60�n . <br /> STATE OF CALIFORNIA .� <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 O 1 NEW PERMIT O 3 RENEWAL PERMIT Z5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION'&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OPERATOR <br /> ADDRESS / �j� .� NEST CROSS SjREE /\ �� PARCEL N(OPTIONAL=r <br /> CITY <br /> NA�1 STATE ZIP(CY E ['1 r SITE PHONE X WITH AREA CODE <br /> // �.3 D9�3y.-3ZSz <br /> ✓ BOX LOCAL•AGENCY <br /> TO INDICATE CORPORATION �f,iN61VIDUAI PARTNERSHIP [] 000UNTY-AGENCY' (]STATE-AGENCY' 0FEDERAL-AGENCY' <br /> i/ DISTRICTS' <br /> If owner of UST Is a public agency,completee.following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR 0 RESERVATIONINDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 4 PROCESSOR OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> r. {S L11,C16 ! 5 <br /> NIGHTS: NAME( AST,FI sT) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> orl <br /> MAILING OR STREET ADDRESS r, ✓ x b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> �On H y l 'Ro 5-ide -3)V CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0FEDERAL-AGENCY <br /> CITY N ME STATE ZIP CODE PHONE#WITH AREA CODE <br /> �ia_ Ag ) G✓A 9 '57 S7�,� <br /> III. TANK OWNER INFORMATION.(MUST BE COMPLETED) <br /> NAME F OWNECARE OF RESS INFORMATION ' <br /> �, �an� �Y, r jv1 5 '� 'L� <br /> MAILING OR STREET DRESS II ✓ c b indicate 0 INDIVIDUAL LOCAL-AGENCY = STATE-AGENCY <br /> -S;;, yJ d c� / ��[� ►� 1O LJ CORPORATION 0 PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY N CODE <br /> Lr N-6>� STATE 21P CODE� ,PHONE 0 #WITH R.3—Z-7t / <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916))``11//322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -1 D 8 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bindicate 0 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT 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. ll. III. <br /> THIS FORM HAS BEEN COMPLETED UND R PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAM/EE(P( SRINTED 8 SIGNOWNER'S TITLE DATES MONTWDAYIYEAR <br /> �t L I All�vj/"vwb�OL �""'Lrj 1 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 12-1 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> p-5 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE)OF MFOR TI Y. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANk REGULATIONS <br /> FORMA(3(93) e4 --------- FOR0033A-R7 <br />