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`A `STkTE�F ALIFORN I A.{ q b <br /> STATE WATER RESOURCES CO OL BOAR <br /> UNDERGROUND STORAGE TANK PERMIT APPLI ATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/STTE D <br /> MARK ONLYI NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 d AMENDED PERMIT a e TEMPORARY SITE C OL SURE <br /> 11111A 0- 1. <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) it <br /> DBA OR FACILITY NAME _ �— NAME OF OPERATOR _I/ �� <br /> ADDRESS ' `L/5 t S' o NEAREBT CRO S 177!91 <br /> CITY NAME � PARCEL(OPTIONN.) <br /> . C SL ('/ C ,4e ©�V CA ZI�/S CODE SITE PHONE P WITH AREA CODE <br /> ✓BOX ED CORPORATION 0 INDIVIDUAL 0!�PARTNEASHIP 0 LOCAL-AGENCYf�COIftlTY-AGENCY- (]STATE-AGENCY' O FEDERAL•AGENCY' <br /> TO INDICATE DISTRICTS <br /> '10 dUSTb8Rp4@9 M.mMP1 Mm.bbwb¢romadswwybora0'Nbbn,WiDn"OMNMt ops NAUST <br /> TYPE OF BUSINESS W 1 GAS STATION Q 2 DISTRIBUTORQ VIFINDIANI#OFTMKSATSITE E.P.A I.D.I(oPUanel) <br /> Q 3 FARM d PROCESSOR RESERVATION <br /> Q Q 5 OTHER OR TRUST LANDS 4 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: ,FIRST)�/� PHONE WITH AR ODE DAYS: NAME(U PHONE d WITH AREA <br /> NIGHTS: WLME�ST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FlRST) PHONE N/WITH AREA CODE <br /> C`//- B / L /J�/ / <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLFTFD) <br /> NAME /N / ARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ EUUiICm:a <br /> O INDIVIDUAL CD LOCAL-AGENCY QSTATE-AGENCY <br /> OAS/6SS f�CORPORATION PARTNERSHIP I�COUNTY AGENCY ED FEDERAL-AGENCY <br /> CITY NAMESTATE ZIP CODE PHONE&WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> C 7 /�v✓Hf <br /> MAILING OR STREET AAD-DRESS / ✓ &mbbdnl& ,O--�F INDIVIDUAL LIX.WAGENCY ED STATE-AGENCY <br /> O G / O OORPORATION A, . ARTNERSHIP O CWNTY-AGIRM O FEDERAL-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE P WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Oo�b YldulA SBF NSURED O 2 GUARANTEE Q 3 INSURANCE f=A SURETY BOND Q 5 LETTER OF CREDIT =S EXEMPTION 0 7 STATE FUND <br /> O&STATE FUND&CHIEF FINANCIAL OFFICER LETTER fie STATE FUND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O SOOTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) _ TANKOWNERS TITLE DATE MOM FbIDAYNEAR <br /> LOCAL AGENCY US LY ecl <br /> COUNTY R JURISDICTION• FACILITY K <br /> EE <br /> LOCATIONCODE-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(B-p5) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />