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,6WA f <br /> n STATE OF CAUFORSA .° <br /> STATE WATER RESOURCES CONTROL BOARD 3 ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA �y <br /> COMPLETE THIS FORM FOR EACH FACILrTYISITE <br /> MARK ONLY 0 / NEW PERMIT 0 0 7 PERMANENTLY CLOSED 317E Y <br /> ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT <br /> Q 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION It ADDRESS-(MUST BE COMPLETED) 1i/,,)//Q-:F <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> =F-YACO err s <br /> ADDRESS NEAREST CROSS STR PARCELI(OPfx>NAU <br /> CITU NAME <br /> STATE ZIP( 917E PHONE#WITH AREA CODE <br /> ✓ <br /> BOX <br /> TOINDCATE ED CORPORATION Q INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERALAGENCY' <br /> ' <br /> It center al UST Is a public 8 B DISTRICTS' <br /> p agency,c9npleta the following: al Su rvear of dNMbn,eecYbn,W office which aperalm the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN 10 OF TANKS AT SITE E.P.A 1.D.#repfAmn4 <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> O ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> FNI54TSPINAIE <br /> S: ME VAST,FIRST) �_, PHONE 0 WIT AREA CODE D YS:NAME �FIRST) PHONYM4H AREA CODE <br /> e J /�...w ^Al <br /> o N i Ck X04S-toll <br /> (LAST,FIRST) PHONE#WITH AREA CODE NI(3HT3: NAME(LAST,FIRS PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> "�awf ^. FA. a CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ,AV/ ✓ as bkbkdr INDIVIDUAL = LOCAL-AGENCY 0STATE-AGENCY <br /> 2 S tv a CORPORATION O PARTNERSHIP =COUNrYAGENC/ O FEDERALAGENcY <br /> CITY FUME l--�• 8�7jt ZIPCODE� PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMA ION-(MUST BE COMPLETED) <br /> NAME OFOW�NER e c arr� CARE OF ADDRESS INFORMATION <br /> MAIIILI`{1NG_1OOR STR�EVEEET ADDRESS f-j � ^� ✓ Ow b4bkale � INDIVIDUAL 0 LOCAL-AGENCY l�STATE-AGENCY <br /> 25O rDtT�Cl I�CORPORATION O PARTNERSHIP COUNTYAGENCY FEDERAL AGENCY <br /> CITY NAME �� STATE ZIP ODE // � PHONE#WITH AREA CODE <br /> S 3-f�p <br /> IV.BOARD OF EQUALIZATION LIST IITORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(7K) HQ M44- - z fo $ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Icyb O 1 SELF-INSURED 0 2 GUARANTEE O 3 INSURANCE 0 4SUREIYSOND <br /> D 5 LETTEROFCREDIT Q 5 EXEMPTION 0 99 OTHER <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 II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED B SIGNED) OWNERSTITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITYi <br /> mI-Q 13 11 L3 19 7 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL I;z � j <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIONONLYp.. //' <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS f0 �(D O``' <br /> FORM A(3'93) FOR003MA1 <br />