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v <br />Pt"OV w�.S C <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY 1 NEW PERMIT r-] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY nIT/, <br />ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE 0 <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />m <br />DBA OR FACILITY NAME <br />Z <br />NAME OF OPERATOR � �^ <br />—Zp <br />,o-a� Gi �oBS <br />M <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL R (OPTIONAL) <br />OAS <br />1,19 17--4, _1061-6 <br />STATE <br />CITY NAME <br />�Q <br />STATE <br />ZIP CODE " ��� <br />ITE PHO E #WITH AREA CODE <br />5Z azZ <br />CA <br />�' G-`� <br />✓ BOX D CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY COUNTY -AGENCY' STATE -AGENCY' 0 FEDERAL -AGENCY' <br />TO INDICATE DISTRICTS <br />' ff 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 r4zZ301 GAS STATION O 2 DISTRIBUTOR <br />a ✓ IF INDIAN <br />N OF TANKS AT SITE <br />E. P. A. I. D. R (optional) <br />3 FARM 4 PROCESSOR 5 OTHER <br />D � <br />RESERVATION <br />OR TRUST LANDS <br />I <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARYI - ontional <br />DAYS: �N,A�ME (LAST, FIRST) %- PHON k WITH AREA CODE <br />+ <br />45_ <br />DAYS: NAME (LAST, FIRST) PHONE ff WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE b WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE M WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />Ga4cf-r–Tr <br />CARE OF ADDRESS INFORMATION <br />G ,le'd-00-5. <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q <br />CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE ff WITH AREA CODE <br />'/-a "1 <br />5Z azZ <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />IV. <br />CARE OF ADDRESS INFORMATION <br />MAILING ORSTREET <br />✓ box to indicate Q INDIVIDUAL LOCAL -AGENCY Q STATE -AGENCY <br />gqADDRESS ,�1 <br />4 Z ti �� <br />CORPORATION Q PARTNERSHIP (] COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />� � / <br />STATE <br />ZIP CODE /\ <br />o � -7— <br />7— <br />PHONE p WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ 4T4-1-1, I rI I n <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to ardxate f1 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND 0 5 LETTER OF CREDIT l= 6 EXEMPTION O 7 STATE FUND <br />O 8 STATE FUND s CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND 8 CERTIFICATE OF DEPOSIT E-1 10 LOCAL GOVT. MECHANISM O N 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. E-1 11. E-1 III. ' <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, 1S TRUE AND CORRECT <br />TANK OWNER'S NAME (PRINTED & SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br />7 <br />LOCAL AGENCY USE ONLY <br />COUNTY It JURISDICTION M FACILITY k <br />LOCATION COQ -OPTIONAL CENSUS TR CT -OPTIONAL SU�� DISTRICT CODE - OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT T (1) OR MORE PERMIT APPLICATION - FORM 8, UNLES IS A CHANGE OF SITE INFORMATION ONLY. 44 <br />FORMA (6-95) OWNER MUST FILE THIS FORhi THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU ,TORAGE TANK REGULATIONS <br />