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Esso•...'c <br /> STATE OF CALIFORNIA *M04 <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILTrYISrrE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> verliftf <br /> ADDRESSNEAREST CROSS STREET PARCELI(OMIDW <br /> $QDo 5. 1 a/t /38see. Drxow /gr7-,260 - q-i? <br /> CITY NAME STATE ZIP CODE SITE PHONE 0 WITH ARFA CODE <br /> S aek-f40 cA 5�o1 — <br /> T IO x BOX l�CORPORATION O INDIVIDUAL O PARTNERSHIP 0 LOCDISTA.AGENCY O COUNTY-AGENcv O STATE-AGENCY O FEDERAL-AGENCY <br /> ri7E-6�SS Q CTS <br /> T GAS STATION Q 2 DISTRIBUTOR - ❑ RESERVNDI N I OF TANKS AT SITE E.P.A. L D.a TaplmatI <br /> ❑ 3 FARM Q 4 PROCESSOR 05 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE I WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> p%o <br /> NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION - <br /> /ld/P �' <br /> MAILING OR STREE ADDRESS .1 IMbbAcaA 0 IN04VIOUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> •�, OX / 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> LockWo C4 1 A07 —n <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNERCARE OF ADDRESS INFORMATION <br /> 4'S 77r <br /> MAILING OR STREET ADDRESS biMbm 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 0 CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739.2582 if questions arise. <br /> TY(TK) HQ 4 4 -1 1 1 1 J-T� <br /> V. 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: L❑ IV III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY a <br /> O o MAJOR so <br /> LOCATION CODE -OP77ONAL CENSUS TRACTI •OPTpAUL SUPVISOR•DISTRICT CODE -OPTAOAUL <br /> 97 1 <br /> rso z 3 9 <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 /> FOR=AA2 <br /> FORM A 1490) , <br />