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0 �CCS <br /> STATE OF CALIFORNIA �� „.... cO <br /> STATE WATER RESOURCES CONTROL BOARD Wim, r o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F?9 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM E] 2 INTERIM PERMIT Q 4 AMENDED PERMIT E:1 6 TEMPORARY SITE CLOSURE I L} <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAS C WK00 NAME OF OPERATOR` <br /> U ^ O02' � <br /> L <br /> ADDRESS IC,,' NEAREST CROSS STREETT PARCEL#(OPTIONAL) <br /> F"0 L-006*, SoW-P4M ROM P C). P0114C4,C7 DE L66( l- C7 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 5T0CKT N CA q5 2,09 2 - —n-© q-1 <br /> ✓BOX CORPORATION J<INDIVIDUAL = PARTNERSHIP D LOCAL-AGENCY Q COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> If 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 :5<1 GAS STATION 0 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR Q 5 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 /> RICK (yCWzALE S z 4-11 -34- (09 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> glc,r, CToiNZA L e S (ZC->q) 4 7-7-'50A <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAR OWR() � w f7A ��R CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> CoB-7 5AsE5r (�A N A lye,. =)CORPORATION Q PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> tV R L cx,—K r CA 95 Z8 0 Ga 9 S -3180 63 Z-- 3 9 8 <br /> III. TAN OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOF O ER CARE OF ADDRESS INFORMATION <br /> 1�1 <br /> MAILING OR STREET ADDRESS ✓ box to indicate 'gf INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 6(0(00 L-,,6WF—R G T-MA =CORPORATION PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> s`To CkToN. CA 9S 2. L2 1-7 0 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -1 1 1 1 1 -1 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED =2 GUARANTEE 19 3 INSURANCE Q 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND <br /> O 8 STATE FUND 3 CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 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 SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. it. 111. <br /> o�p4 ,,w-THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> T� TANK QMddIPM NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHiDAYNEAR <br /> M -, 1rAxt tl I 12 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 37Z(o <br /> EE 14 1 :311 111 I 1. I ro�gq <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT I GAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORMSTHE LOCAL AGENCY IMPLEMENTING THE UNDERGROWTORAGE TANK REGULATIONS <br />