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• 0 `ppURCl9 <br /> STATE OF CALIFORNIA F' cO <br /> STATE WATER RESOURCES CONTROL BOARD W dam, a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> •Cil,.pp N,r <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT E:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME T Iq I w0 NAME OF OPER <br /> ADDRESS vv. 10 REST CROSS sT�� PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> S, L CA <br /> ✓BOX CORPORATION INDIVIDUAL O PARTNERSHIP E:j LOCAL-AGENCY COUNTY-AGENCY' D STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 8 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 0 2 DISTRIBUTOR ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) P ONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> i <br /> k1 0 <br /> NIGHTS: NAME(LAST,FIRST)/. ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> l! SIM - 7 J <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFQ) <br /> NAME) �� CARE OF ADDRESS INFORMATION <br /> , <br /> MAILING OR STREET ADDRESS ✓ bcx to i w'. INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> r 1 .��_ " CORPORATION [=) PARTNERSHIP COUNTY-AGENCY a FEDERAL-AGENCY <br /> CITY NAMSTATE ZIP CODE PHONE#WITH AREA CODE <br /> YD "[D i>J cA Z i o o)S�9 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> as <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION PARTNERSHIP 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) HQ 4 4- - <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 0 4 SURETY BOND Q 5 LETTER OF CREDIT =6 EXEMPTION 0 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND b 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> �r( <br /> OWNER'S/NA�ME�(P�RI�NTED 1&SIGNATURE) / /I TANK OWNER'S TITLE DATE ;7i/DAY YEAR <br /> W A-�.f� <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# j(i(1 <br /> EE <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> a <br /> THIS FORM MUST BE ACCOMPANIED BY AT AST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFO MA ION ONLY. <br /> OWNER MUST FILE THIS FOIW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR10STORAGE TANK REGULATIONS <br /> FORMA(6.95) <br />