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Pt9oV n°CS C <br /> STATE OF CALIFORNIA Ap ° <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A as <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> PERMIT NEW 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 P♦R* AQENTLY CLOSED.SITE <br /> MARK ONLY 7 D 0 0 l��C ti <br /> ONE ITEM 2 INTERIM PERMIT 0 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 /> u V_5 0 k) ST e P `.,v D �--tAR S <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ilP ODE SITE PHONE#WITH AREA CODE <br /> CA o1 23 7— 197Y <br /> ✓BOX 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY' D STATE-AGENCY' 0 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 ✓IF INDIAN 1#OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 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) PHON <br /> - E#WITH AREA CODE <br /> C 9 23 — 5 7S C <br /> 44)N <br /> I b <br /> NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �4NP6 k I <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTF1)) <br /> NPM { CARE OF ADDRESS INFORMATION <br /> �hK <br /> MNC%OSTREET ADDRESS ` /� 1 ✓ �x to`"'=�' l�INDIVIDUAL E:] LOCAL-AGENCY 0 STATE-AGENCY <br /> UU �j� `/ C/J` 0 CORPORATION b PARTNERSHIP Q COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> M�pi 40 l STAT ZIP copf— PHO � <br /> CIITH AREA CODE C <br /> MIII. TANK OWNER INFORMATION-(MUST BE COMPLETED) �S �] <br /> NAV&OF OWNER CARE OF ADDRESS INFORMATION <br /> CL <br /> W&IING OEC STREET AD R'Ss / J ✓ boxtoindicate EXINDIVIDUAL E:] LOCAL-AGENCY STATE-AGENCY <br /> `J U / 04 C%�!/ =CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> M <br /> STAT 7}P QBE^� PH E#y1ljTH VSE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(91166)322-9669 if questions arise. /J V\ <br /> TY(TK) HQ F4]4]- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 , SELF-INSURED = 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 0 9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 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: I.= if.[—] III. <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 MZ DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <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 REGULATION <br /> FORMA(6-95) ,'��1� � ����"2/7)A� �� <br /> W�/II�/ ��WMM�/// <br />