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.eeoua e <br /> STATE OF CALIFORNIA o` <br /> / STATE WATER RESOURCES CONTROL BOARD wy�� a a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA ?o � o <br /> •DPN,•. <br /> COMPLETE THIS FORM FOR EACH F ITYISITE <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT CHANGE OF INFORMATION O 7 PERMANENTL CLO E <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DaA OR FACILITY NA NAME OF OPERATOR <br /> G 24V r! 7= <br /> /� <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 'y S F 1•A1� a <br /> CITU NAME <br /> STATE ZIP CODE175216 �t SITE PHO�N WITHIDTOIN BOX 0�PORATION INDIVNUAL 1�PARTNERSHIP 0 LOCALCTSENCY (]COUNTY-AGENCY STATTEAGENCY 0 <br /> DISrFU <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ///''' O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#Optimal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:jjAME(LAST.FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE A WITH AREA rMF <br /> NIGHTS: NAME(LAST.FIRSTV PHONES 0 WITH AREA CODE NIGHTS:aN•AAMIE(`L I.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> p� M <br /> MAILING OFf STREET ADDRESS d ✓b^4 bkWica wn INDIVIDUAL (]LOCAL-AGENCY STATE-AGENCY <br /> NR �L vlI f�CORPORATION (] PARTNERSHIP COUNTYAGENCY FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> I-fsFN O f.Ct v <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR ST ET ADDRESS � ^ ✓ bo oIntlkzN 0 INDIVIDUAL f� LOCAL-AGENCY O STATE-AGENCY <br /> ®I/l L✓ Q CORPORATION O PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME /�W ro STATE' ZIP C Q��-77 PHONE IIWITFj AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3323-9555 if quesfions arise. //6_ <br /> TY(TK) HQ 4 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THJrWTHOD(S) USED <br /> ✓ba bind'baN I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 ETTSURETY BOND <br /> 5 LER OF CREDIT =6 EXEMPTION 0THEfl <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.O it.IVIII.O <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 TIRE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY W,QS <br /> 3 COUNTY 7t ISDICTIONTeFAC TTV# <br /> Tel <br /> LOCATION CODE -OPTIONAL C SUS TRACT# -OPT AL SUPVVISOR-DISTRICT -OPTIONAL 5 <br /> d 32 <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 /> FORM A(5-91) ` FORM3A 5 <br /> �10i <br />