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STATE OF CAUFORMA <br /> _JE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR'! A <br /> COMPLETE THIS FORK FOR EACH FACILITY;SITE <br /> MARK ONLY I_ I NEW PERMIT I_I D RENEWAL PERMIT 5 CHANGE OF INFORMATION �— T PERMIAN <br /> CNE ITEMPERMIT — S <br /> 2 iNT[RIM I_ s AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY SITE INFO ATION&ADDRESS-(MUST BE COMPLETED) <br /> .SA QR FACILITY NAME LA <br /> INANE OF OPERATOR <br /> ACCRESS <br /> 3NEAREST CROSS STREET PARCELAIC"GNAU <br /> vITY HANE ' <br /> STATEZIP Opp <br /> CA 1 lWITH EA.CCO" <br /> /v 6 ISI;Z rz <br /> ip INGCATE '1 CCRPCRATCN INDIVq)U _PMTNERSWP LOCAL.AGENOY Q COUxry.,10E,YCY C STATE-AGENCY FEDERAL <br /> DISTRICTS <br /> TYPE Of 3USINESS '— I GAS STATION L Z OLSTRIaUTOA J IF INDIAN A OF TANKS AT SITE E.P.A. L D.s <br /> JRESERVATICN IoptNXMp <br /> ] FARM C1 a PRCCc'SSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•*phonal <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST, PHONE I WITH AREA CODE NIGHTS:NAME(LAST.FIRST) a <br /> II. PROPERTY OWNER INFORMATION-IMUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> VA%L!`.G OR STREET ADCRESS ✓ ST,evgrAu L__j INDIVIDUAL (1 LOCAL-AGE4CY STATo-AGENCY <br /> I_CCRPCRAn0N Cl PMTNERSWP G' COUmYY4G'[NCY C FEDERAL AGENCY <br /> CITY NAME STATE I LP COCE PHONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ RPiLNKYA Q INDIVIDUAL CI LOCAL-AGENCY C:j STATE-AGENCY <br /> El COAPORATIM 0 PMTNERSWP 0 COuNrydOENCY Q FEDERAL44EW <br /> CITY NAME STATE I ZIP CODE PHONE P WITH AREA CODE <br /> IV.BOARD OF EQUALIZATIONUSTSTORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 it questions arise. <br /> TY(TK) HQ F4-1-4'1- <br /> V. <br /> 4 -V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> J Eu emuu !=; I SELF-INSURED =3 GUMANTEE S INSURANCE a SURETY SOxO <br /> [=S LETTER OF CREW =6 ExEMPTION Q ISP OuTR <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notir—tion and bilTLng Will be sent to the lank owner unless box I or II is chec(ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD 9E USED FOR LEGAL NOTIFICATIONS AND BILLING: L a IL❑ DL❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPL.CANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE <br /> DA TIE MONTWpAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION R FACILITY r <br /> 57ci�47 <br /> LOCATION CODE -CPFVML CENSUS TRACT A .Op TKlA4L SUPVISOR-DISTRITCOpE -OP NAL <br /> 2— - b <br /> THIS FORNIMUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMAPM ONLY. <br /> FORM A(`+SI) <br /> I <br /> FGI6GSlMS <br /> / L <br />