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• i <br /> ft.���ma <br /> STATE OF CALIFORNIA A� cO <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD , a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> •C�l,Ipp N� <br /> MARK ONLY 1P!<1 NEW PERMIT O 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION 7 PERMANENTLY LOSED.SITE <br /> ONE ITEM 0 2 INTERIM PERMIT Q 4 AMENDED PERMIT El 6 TEMPORARY SITE CLOSURE 01 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> stay�5 01 INI rn,4P_KjET 7�q m,o%e- I L2A-TH <br /> ADDRESSOD NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> W.E5T LOf ,E >A LPWG7 I I -� - OSa - 3-�- <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 5ToLIcToN I CA Cf52o6 2-C>9-- 4�,&- )6182 <br /> ✓BOX 0 CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY 0 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 fel 1 GAS STATION a 2 DISTRIBUTOR RESERIF <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 0 4 PROCESSOR 0 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 /> M C, I LRA .Arj lo I <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> IMC I L R 7 'Jf}Y Zc*l-If71- T7 8 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME m I CARE OF ADDRESS INFORMATION <br /> 5Ay � ►�� � ��T H <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> I q o$ Nf�V D!�I V E 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 5T0GKT0nJ CA gS"LO� '2_09-NO2-870T <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> � IMAM Mc I UPATH <br /> MAILING ORS EET ADDRESS ` '�G^ ✓ box to indicate [�INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> 1105- NAV DI.I �/ 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE� ZIP C�E—ZO� PH ONE#WITH AREA CODE D� <br /> SToCkTol� S <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - 012- -t I 6 Z <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate fE� 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND <br /> 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND&CERTIFICATE OF DEPOSIT a 10 LOCAL GOVT.MECHANISM 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.= 11 III.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TA WNER'S NAME(P TED& G ATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> G — L , C)�iv�'� <br /> C L AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#jZ �7 <br /> m <br /> -)36 ) a .3 / IA 1P191 <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,(FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATI N c� <br />