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S Co arw t) (—N , C\Sw 1-O3� D STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORM A v _ <br /> W <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> j� Cil IO <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT F75 CHANGE OF INFORMATION 7 PERMANENTLY�CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT = 4 AMENDED PERMIT E—] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OFERATOR <br /> eco (03�� �(��sT��e 'S�ww& N - <br /> ADDRESS 2."T � �\�e \ NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME ld` STATE ZIP CODE SITE PHO #WITH AREA CODE <br /> e CA as �'1� as -8►�2. <br /> ✓BOX CORPORATION ] INDIVIDUAL ] PARTNERSHIP ]LOCAL-AGENCY COUNTY-AGENCY' ]STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> M owner of UST's a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS TG 1 GAS STATION Q 2 DISTRIBUTOR 0 <br /> RESERVATION <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM ] 4 PROCESSOR ] 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME LAST,FIRS PHCWE#WITH AREA CODE DAYS: NAM (LAST,FIR T) PHO #WITH AREA CODE <br /> �Ai �ccc, <br /> NIGHTS: NA (LAST,FIRSPHO #WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2c '�30 $�A-L �t <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME \\ CARE OF ADDRESS INFORMATION <br /> A0.Co Yco��o �0 , ­ <br /> MAILING OR STREET ADD SSV box to ehdcata ] INDIVIDUAL I]LOCAL-AGENCY ] STATE-AGENCY <br /> .O A �)03iEA611PORATION ] PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE7ZCODE PHO #WI H AREA CODE <br /> s�CA CO% <br /> v�o2-loa3'8 �t� bio -S4o� <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AD`�)�E,SSS ^ `-,, ✓ box to indicate C:] INDIVIDUAL F-1LOCAL-AGENCYED STATE-AGENCY <br /> `Q0 3� ORPORATION 0 PARTNERSHIP =COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHrNE ITH AREA CODE <br /> �G <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - ij 01019FM <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate SELF-INSURED ]2 GUARANTEE ]3 INSURANCE O 4 SURETY BOND ]5 LETTER OF CREDIT I]6 EXEMPTION ED 7 STATE FUND <br /> 8 STATE FUND b CHIEF FINANCIAL OFFICER LETTER I]9 STATE FUND 8 CERTIFICATE OF DEPOSIT ] 10 LOCAL GOVT.MECHANISM ED 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.E:1 II.0 9"�J <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNEMSIJ(PRINTED&SIGNATU TANK OWNER'S TITLE DATE M NT AYNEAR <br /> ��r� NV n �I l � to I r���!7 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# RISDICTION# 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 /> FORMA(6-95) OWNER MUST FILE THIS FOOTH THE LOCAL AGENCY IMPLEMENTING THE UNDERG STORAGE TANK REGULATIONS <br />