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STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BO ���n�VJ (D-e UNDERGROUND STORAGE TANK PERMIT APP41�:AT1 1p; 1(� � U <br /> - COMPLETE THIS FORM FOR EACHACILrrytsrrE <br /> MARK ONLY Q I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a T PER SEa SITE <br /> ONE ITEM C:1 2 INTERIM PERMIT A AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME NAMEOFOPERATOR <br /> D co�/e L ff�y o(JET I 6S <br /> � oK <br /> ADDRESS _ 1 N MESTCRO$SSTREET I PAIIOEL�IOPTUNAU <br /> I ( 5 s Nkvb <br /> CITY NAME STATE ZIP CODE SITE PHONE A WITH AREA CODE <br /> —kkg�t, CA 19 5 37 6 — 3� / <br /> To INDICATE O CORPORATION INOIVDUAL �PARTwASWP Q Lom.AAGENCY O COUNTYAGENCY Q STATE-AGENCY Q FEOERAL44GENCY <br /> TYPE OF 3USINESS 1 GAS STATION IJ 2 DISTRIBUTOR p SEROISTRICTS <br /> VINDIANATION s OF TANKS AT SITE E.P.A L D.A(9ptwpAq <br /> Q 3 FARM Q 49 ESSOR 3 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•apdaW <br /> DAYS: NAM (LAST,FIRST) PHONE A WITH AREA CODEDAYS: NAME(LAST,FIRST) <br /> 570-7-7 8 see, <br /> NIGHTS: NAME(LAST.' T) PHONE A WITH AREA CODE NIGHTS:NAME(LAST.FIRST) <br /> p v WITH AFICAc <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MARWGCRSTRE/ADORES$ ✓ e�CnOrAY Q BONGUAL J LOCALAUDICY Q STATE-AGENCY <br /> 1,5 <br /> 1 d O M S CORPORATION Q PMRI6RSHP I= COUNrYAGENCY Q FEDEMAGENCY <br /> CITY NAME STATE ZIP COOSPHONE 6A4 'q `J� 6 I '20,-7 <br /> 20-7-7 9�WITH AREA CODE 60 O <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) / S <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 0 ✓ oo'nnaleiM a INOMA OCA <br /> LAGENCY Cj STATEAGENCY <br /> lS b D Le Q C'Wo ORATION O PARTNERSHIP p COUKrY+GEICY a FEDMAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> `1'( b 4 I a,- I q SD 57t--77 �0 ° <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 it questions arise. �T <br /> TY(TK) HQ 4 4 -F ��� IV&, ��G( �L �+ // <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓m,Al:l�.. D I SELF+NSURED a 2 GUARANTEE Q 7 86URANCE a•SLRETY BOND <br /> S LETTEROFCaEOIT =a EXEMPTION <br /> 98 oiHER <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 LEGA NOTIFICATIONS ANO B81NLl L= IL= IR. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLA:ANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* - JURISDICTION 8 FACILITY t <br /> Q <br /> LOCATION COD -OPTIONAL (CENSUS T 37- TA -OPTV0j , Q $UPVISOq.OISTRICT CODE -OPTIONAL <br /> THIS FORM MUSS T BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> :ORM A 15-91) FORGOSIA3 <br /> •�nr <br />