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' a�,,owces c <br /> 0 <br /> STATE OF CALIFORNIA Aa o <br /> STATE WATER RESOURCES CONTROL BOARD w dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE t� <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 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 /> ,r4 &E A CON C"-M Va L- S�1 f' LA <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1001AVE <br /> CITY NAME STATEZIP CODE SITE PHONE#WITH AREA CODE <br /> M -c t� CA S 3 3 - z - 9 <br /> ✓BOX 0 CORPORATION Q INDIVIDUAL O<PARTNERSHiP Q 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 1 GAS STATION ❑ 2 DISTRIBUTOR REV IIF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 3 <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 /> -- " L L. <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> L41�- -2,-0 9 -833- 37-L " Og- j?f <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE CO"PLFTFI]) <br /> NAME CARE OF ADDRESS INFORMATION <br /> K <br /> MAILING OR STREET ADDRESS ✓ bcx,o`=a' O INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 3 k V I LA-1 D Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Jnr v i LG�t c.>�4 _ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxio indicate Q INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND = 5 LETTER OF CREDIT 0 6 EXEMPTION O 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 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 SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ It.❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHfDAYNEAR <br /> LOCAL AGENCY USE ONLY a <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) <br /> OWNER MUST FILE THIS FORIW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR`0STORAGE TANK REGULATIONS V' <br /> (R 3�20 1U <br />