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STATE OF CALIFORIIA /;�" " �• � <br /> STATE WATER RESOURCES CONTROL BOARD <br /> Lllvucnhnvulvv ioI vnrAAac I Y,Ian rcm,,i I .NrruvN I ION • t-UYifd A <br /> y <br /> GUh1Y LCIC INS FvnM FUO LAl.r1 FAULII IIJIIL <br /> MARK ONLY I NEW PERMIT a 3 RENEWAL PERV:T 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM 2 INTERIM PERMIT Q d AMENDED P'c RViT 6 TEMPORARY SITE CLOSURE 5 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> IRR nR FACtILITY h^.ME ^ N'AAIE OF OPERATOR <br /> ADDR�c`aS � NE—EST CROSS STREET I PARCEIa(OPTgNAM <br /> �`i C S . �c rJantTl� S r- c�urdn <br /> C'E STACA ZIPC Z D3 - HONER WITH AREA CODE <br /> 5 7 - aD b <br /> ✓ Box <br /> TOINDCAT-e !CORPORATIONINDIVIDUAL O RARTNERSH!P LOCAL A3:NCY COUNTY_AGENCY• O STATE AGENCYFEDERAL AGENCY• <br /> D5TF: -s- <br /> '1 owner of UST is a pub=:agancy,car loe the following:na!ra of Supeivsor of rv:sbn,ia:an,or otf e•dh o ales Irie UST _ <br /> TYPE OFBUS:n'ESS 1GAS STATION 2DISTRIBUTOR ✓ IF INOAN sC=TA\KS AT SITE EP.A. 1.0.a(bptiral) <br /> RESE F':ATION <br /> t—� ] FARM 0 6 PROCESSOR 5 07-cR OR TRUST LANDS 2QU <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST:. PHONE a WITH AREA CODE DAPS: NAME(LAST.FIRST) PHONE a WITHAREACODE <br /> Ll- w/ / -0cl 467 –/crab <br /> WCHTS: NAIVE(LAST,FIRST, PHONE a W'TH AREA CODE NuHTS: NAIVE(LAST.FIRST) PHONE a WITH AREA CODE <br /> n n "9 D-3?&/ <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> .NAVE : PD kllt� /77/ <br /> L-OW3 oc < �o G66s TCi� _ s <br /> M A'LIRG OR STREET ADCRESS / C ✓ x�eegaa:e �_ .;DOAL LGCALAGENCY — STATE-AGENCY <br /> )3�'L �( $j}_J f�' C.SY=,<'^,N C.•:E'nSV.IP CCU!JY AGENCY 1 FEOEFALAGENCY <br /> ti NAME <br /> STA-= ZIP COTE PHONE a WITH AREA CODE <br /> Lad <br /> 0:3 '3S-4qz 12.0 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW,ER CAP E OF ADC=ESS IN:=CR:Y.`!ON <br /> 5 4\1 <br /> MAILING OR STREET ADDRESS ✓ Ou blri<a:a =7 IND'VIDUAL O LOCAL AGENCY = STAT,E"AGENCY <br /> C CCRPCRATION C! PARTNERSHIP 0 COUNTY AGENCY 1-,' FEOERALACENCY <br /> CITY NAME STA-E I ZIP CODE PHONE a WITH AREA CODE <br /> I <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ 4 4- -=�, <br /> V. PETROLEUM UST FINANCIA RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ lnc biMdale I SELF-INS'JREO uI 2 CL+ANTEE 3 INSU'RRiCE I= A SUFETY"KNO <br /> 5 LETTER OF CREDT 6 Exzv:TICN 99 CTNER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal ncL(calion and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGALNOTIRCATONS AND BILLING: I.O '[-2'- IIID <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED a S!GNE) OWNER'S TITLE DATE MONTW'OAYYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILrTY#,9t) <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> NZ )zap <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 /> OWNER MUST FILE THIS FORMA uqi THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUIHQSTORAGE TANK REGULATIONS <br /> FORM A(393) FCRIXg5lA1 <br /> .� �a a3 y/* <br />