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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT F-] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ z INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE j <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> D R FACILITY NAME NAME OF OPERATOR <br /> I t N E.rl`wrQ-i 'P t S'C`R-+ 6 WTreO 6 JY1 G /04 N I-t-t°o"L-T 7>144,i /AJ Z- <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 160 I 4 aSi ,vu m=_ MqNr— <br /> CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE <br /> ✓BOX TA CORPORATION INDIVIDUAL ] PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' ]STATE-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 t GAS STATION a 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> ] 3 FARM ] 4 PROCESSOR ] 5 OTHER OR TRUST LANDS <br /> f' 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 OD <br /> C I�teia-4�+< e t> r3nsk .�toq ��'y >rrV2 S' ice' 1vte.t�.&r F . tC� -e> 2 4jb7--o& / <br /> i NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> W.Il t4iLi&c e. U C!S k. -7 n t2S-log7 7 TT+%,%c"11 4Z 7v7 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME, CARE OF ADDRESS INFORMATION <br /> MAILING�+O(►RSTREETADDRESS ✓ box to indicate En INDIVIDUAL ] LOCAL-AGENCY ] STATE-AGENCY <br /> T (24A CORPORATION (] PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITYNAMESTATE ZIP CODEPHONE#WITH AREA CODE <br /> Lt /07 4f03 <br /> " IJ <br /> i <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> r NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> I I V F1 <br /> MAILING OR STREET ADDRESS p y t/ boxtoindicate ( INDIVIDUAL LOCAL-AGENCY ] STATE-AGENCY <br /> l <br />`.' ke c, na-At CORPORATION ] PARTNERSHIP ]COUNTY-AGENCY FEDERAL-AGENCY <br /> it CIN NAME STAVE ZIP CODE THYNE#WITH AREA CODEr, a St-G3•- 1 r sS <br />` IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> 7�KM'r 4 4- 4016F(07410 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED ] 2 GUARANTEE ]3 INSURANCE ]4 SURETY BOND ]5 LETTER OF CREDIT ]6 EXEMPTION n 9 STATE FUND <br /> ]8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER ]9 STATE FUND&CERTIFICATE OF DEPOSIT ] 10 LOCAL GOVT.MECHANISM ] 99 OTHER <br /> 7 <br /> V EG L N TIFI ATION AN B LIN ADDRE S egal .tific ti P Zn b jlirjwill be Slr t t t ie ttaal�l�own r unless bo for III* chec 4. ed. f jl <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LE NOTIFICATIONS AND BILLING: L D IL Q Ill.Ej <br /> ITHIS FORM NAS BEEN COMPLETED UNDER PEND`OF PERJURY,AND TO HE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURES TANK OWNER'S TITLE DATE MONTHiDAY/YfAR <br /> i <br /> i LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> f m <br /> V LOCATION CODE -OPTIONAL t CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> r' <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 FO 95rFITHE LOCAL AGENCY IMPLEMENTING THE UNDERGR*STORAGE TANK REGULATIONS <br /> i <br /> x <br />