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ST ATE OF CAL:FCRNA :�• I„q-`•, <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> / r UNDERGROUND STORAGE TANK PERMIT APPLICATION • FOR`. A S5� <br /> y <br /> COMPLETE THIS FORM FOR EACH FACUTWlSITE <br /> MARX ONLY I_ I NEW PERMIT %i 3 RENEWAL PERMIT 024 CHANGE OF :NFCRMATICN T PERMANENTLY C SEJ SIT& <br /> CNE ITEM 1 2 INTERIM PERMIT A AMENCEO PE?MIT 1 a TEMPORARY SITE CLOSURE / <br /> I. FACILITY,SITE INFORMATION 3 ADDRESS•(MUST BE COMPLETED) <br /> OdA CR:AG'.LITY NAME NAME OF CPE�AiOR <br /> 2;A 9A LF 5 - r, <br /> AGGRESS NEAREST CROSS STREET I PARCEL I(OPTIONAL) <br /> 6 0 LL.i f� C+ a= r ' " <br /> C;^I NA�;E � IST Tt <br /> CA I ZT; � SITE PHONE A_ CODE <br /> ✓ 3C2 <br /> TC INDICATE G^.PPoPAP.ON Q;NDNICUAL _PMTNERSNP `,LOCALAGENCP Q COUMTYAG'c-YCY Q STATE AGENCY Q :E^,ERALAGENCY <br /> J6TaO:5 <br /> 'YRE OF 3USINESS J I GAS STATION = 2 cisTR:au-OR ✓ F NOIAN •OF TANKS AT SITE E.P..L L 0.A fW Wl <br /> j 1 fa PRCCE' Ca I S OT- a RRESERVATICN <br /> 3 ;AAM <br /> TRUST LNIOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> >YS: NAME(LAST,FIRST PHONE A WITH AREA COCE DAYS: NAME(LAST.FIRST) <br /> 0 <br /> NKAITS: NAME(LAST,FIRST) PHONE AYnTH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ow c E anTu sacs r^ec <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NA;AE I CARE OF AOORESS INFORMATICN <br /> VA&NG OR STREET ADCRESS ✓ Ma+w[au Q INDIVOU.AL Q LOCALAGENOY Q STAr-c AGENCY <br /> IQ CORPORATION Q PARTNERSAP ` COUNTYJGENCY Q FSCERAL-AGENCY <br /> CITY NAME I STATE I ZIP COCE PHONE A WITH AREA COCE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> +11NE Of OWNER CARE OF AGGRESS INFCRM nCN <br /> AAIL'AG OR STREET ADDRESS ,/ =NAl9fJfA Q WDVVIAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> r CORPORATION Q PARTIERSNP Q COUNTYAGE.NCY Q :MERALAGEACY <br /> CITY NAME STATE I ZIP COCE I PHONE A WITH AREA COOE <br /> IV.BOARD OF EQUALIZATION�—U—ST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 I I—I I -I ro t `N 6 r— 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY'-�1(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓wnror� Q I SELF+NSUREO 0 2 GUARANTEE = 3 NWRMCE Q A SUREiYd <br /> Q S LETTEACFCRE7T f= A 9fENPMON Q W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing Will be sent to the tank owner unless box I or II's checked. <br /> CHECK ONE SOX INDICATING WNIGI ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLNr, L a IL= lIL u <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANO TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLDANrS NAME,PRN1.0 b SIGNATURE) APPLiamrs TITLE DMe MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY way <br /> COUNTV s JURISDICTION t FAC;LRY At <br /> 7',1-� S �� Eaw= <br /> LOCATION CODE .OPrfoN (CENSUS T;;jr)CNAL I SUPVISOR.DISTRICT CODE -CPnCNAL <br /> HIS <br /> i FORM MUST 3E AC..OMPANIED BY AT LEAST p)CR!1%7RE PERMIT <br /> APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF S(TE WFTIW�.cN <br /> THIS <br /> / A.S <br />