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CgOUAC�S <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMAON <br /> s , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION r;.PERIOANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME ` NAME OF OPERATOR <br /> Fuotsn 1�8z, T ,4T__ ?,�, i K S.'atD-1 TtD'�pl � �W�o�xslt� lam. <br /> ADDRESS ro9� �2Si , A"� NEA S�CROSS STREET w4 PARCEL 14 PTIO�jNAL�`-- (( <br /> CITY NAME {o[V STATE r7^ ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA �S 2 IV C2eq) 473 4-s o 3 <br /> ✓BOX CORPORATION INDIVIDUAL D PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' 0 STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> N owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORRESEIRFINDIAN VATION #OF TANKS AT SITE E.P.A. 1.D.##(optional) <br /> Q 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS CA� d Z3 i Z-0 SU <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME q-jST,FIRST)F-i � Z01) 4-73TH AREA 5 o. DAY$ olw(LAST,FIRST) i �A (�PHONE013—REA CO4 <br /> NIGHTS: NAME(LAST,FIRST) �q,�I�(110Nk#WITH AREA CODENIGHTS:NIGHTSS: NAME(LAST,FIRST) J PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM CARE OF ADDRESS INFORMATION <br /> V,Q 1't00A -t hAf1bo 14 4C_too 9k"r—. <br /> MAILING OR STREET fADDRESS ✓ box to mdate 0 INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> Q4r"o Tho U£�q 3bIZSR <br /> CORPORATION 0 PARTNERSHIP O COUNTY-AGENCY a FEDERAL-AGENCY <br /> CITY NAMEk4ln; TATE ZIP CQDE �� PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) �� G�7 <br /> NAME OWNER a ` CARE OF AQWESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxtoindicate Q INDIVIDUAL (]LOCAL-AGENCY STATE-AGENCY <br /> r <br /> ,4'`` pP 1 a+w <br /> {/w +`71 ' CORPORATION (] PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP COQF PHONE#WITH AREA CODE <br /> SvoCkta►� (f5210 CZ©9 413— 4501 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4]-4-]-101 3 ® 6 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate E�] 1 SELF-INSURED =2 GUARANTEE 3 INSURANCE =4 SURETY BOND 0 5 LETTER OF CREDIT =6 EXEMPTION O 7 STATE FUND <br /> 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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 SH OU D FOR LEGAL NOTIFICATIONS AND BILLING: I. It. III. <br /> THIS FORM HAS BEEN COMPLETED U DER PENALTY)F PER AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED 8 IGNAT TANK OWNER'S TITLE DATE NTH/ YNEAR <br /> _5 !r <br /> LOCAL AGENCY USE ON <br /> COUNTY JURISDICTION# FACILITY# <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 /> FORMA(6-95) OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUfTORAGE TANK REGULATIONS <br />