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• gOVN Q <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD Y air o <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />MARK ONLY F—] 1 NEW PERMIT <br />O 3 RENEWAL PERMIT <br />0 5 CHANGE OF INFORMATION O <br />7 PERMANENTLY CLOSED SITE <br />ONE REM INTERIM PERMIT <br />0 4 AMENDED PERMIT <br />0 6 TEMPORARY SITE CLOSURE <br />- I;_�� <br />SITE PHONE # WITH AREA CODE <br />3c1-q66-q1/Lt <br />"I BoxN �C{' <br />T INDICATE Q CORPORATION LJ INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY Q FEDERAL -AGENCY' <br />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 Q t GAS STATION Q 2 DISTRIBUTORQ <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />. ORA OR FACILITY NP.MEK ��� 0 L W O K� <br />NAME OF OPERATOR 61- <br />V <br />ADDRESS <br />8 -WA -i E ('00 i <br />NEAREST CROSS STREET <br />Pit,P <br />PARCEL#(OPTIONAL) <br />CITY NAME <br />STOckaou s D <br />STATE <br />CA <br />ZIP COD <br />�� <br />SITE PHONE # WITH AREA CODE <br />3c1-q66-q1/Lt <br />"I BoxN �C{' <br />T INDICATE Q CORPORATION LJ INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY Q FEDERAL -AGENCY' <br />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 Q t GAS STATION Q 2 DISTRIBUTORQ <br />✓ IF INDIAN <br />IF <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM Q 4 PROCESSOR5 OTHER <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) FMFRGFNry (INTACT aFRCnN mrmmneaVt ..,. H...I <br />DAYS: NAME (LAST, FI PHONE # WITH � EA_CO E <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LOST, FIRS PHONE # WI .H AREA DE <br />A-iF_ FAvq-41 - qy <br />NIGHTS: NAME (LAST, FIRST) PHONE #WITH AREA CODE <br />If. PROPERTY OWNER INFORMATION - (MUST RF rOMPl FTFD1 <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />i CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST RE CQMPI FTFm <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box toindicate Q INDIVIDUAL QLOCAL-AGENCY QSTATE-AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALVMMYN UST STORA ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ 14 14 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box bindicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br />Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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 />OWNER'S NAME (PRINTED & SIGNED) <br />OWNER'S TITLE <br />DATE MONTWDDAAYNEAR <br />Atx l <br />/ <br />LV'wAL AUCI ItoT UJC UNLT <br />COUNTY # JURISDICTION #m flA FACILITY # <br />V ) <br />EF016 Ill <br />LOCATION CODE -OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL 7 �� <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF ift INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKMIB <br />FORMA (3/93) � � y�,RT <br />07 <br />