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STATE OF CALIFORNIA ; <br /> STATE WATER RESOURCES CONTROL BOARD a ¢� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILrrY1SITE 3 Q <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA ORF TY NAME /�R /t n f� NAME OF OPERATOR <br /> G PARCEL M(OPTIONAL) <br /> ADDRESS NEAREST CROSS STREET <br /> �'� ' , <br /> CITY N1y —� STATE ZIP CODE ' SITE PHONE#WITH AREA CODE <br /> ✓ <br /> BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY ] COUNTY-AGENCY Q STATE.AGENCY FEDERAL-AGENCY <br /> 701NOICATE «I�' DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION o 2 OISTRGUTOR Q RESERVATDIDN OF TANKS AT SITE E.P.A. I.D.# (qa!ono!} <br /> 3 FARM Q 4 PROCESSOR W 5 OTHER OR TRUST LANDS e__ <br /> ' EMERGENCY CONTACT PERSON (PRIMARY) I� EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PH?7#WITH AREA CO E DAYS: NAME(LAST,FIRS <br /> G� 2n - p;1`7�NJ l� �� /-, 7,- T77 crtet? PHONE 2 WITH <br /> tNIGHTS: NAME T,FIR PHONE#WITH ARA DE NIGHTS: NAME(LAST,FIRST) <br /> ' 11, PROPERTY OWNER I ORMATION•(MUST BE COMPLETED) CARE Op.ABDRESJ INFORMATION ,{� <br /> NAME r / v.., Or 7!— /"e� f Ala-)eJ X k:,7e,7 <br /> MAILING OR S EET ADDRESS _ ✓ bot b"'dna I INDIYiDUAL ED LOCAL-AGENCY STATE-AGENCY <br /> + I �C7J�- 13F®oa WORPORAPON Q PARTNERSHIP 0 COUNFY-AGENCY FEDERAL-AGENCY <br /> CITY NAME S TE ZIP CODE PHONE.WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> 1 NAME OF pi �� v' 'CARE OF ADDRESS INFORMATION <br /> 1 e_- <br /> ORMAt <br /> / -�� <br /> MAILING Or Ta C f RE ET DRESS ✓ ba te'ndic4w {� INDIVIDUAL LOCAL-AGENCY STAT€-AGENCY <br /> flp O -0 �j e IC/Y) Gt�civ ! CORPORATION 0 PARTNERSHIP [� COUNTY-AGENCY I� FEDERAL-AGENCY <br /> CITY NAME V ST E ZIP CODE PHONE+WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> ' TY(TK) HQ 4 4 -10 13 1�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ' J Dol n indicate 4 SELF-INSURED ED 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BOND <br /> 5 LEITEROFCREDIT 0 6 EXEMPTION 99 OTHER <br /> VI- LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box'I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATCNS AND BILLING: 1.[] 11.0 III•X <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNAT' RE) APPLICANT'S TITLEE MONTHIDAYIYEAR <br /> DAT <br /> LOCAL GENCY USE ON <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> ' LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPViSOR-DISTRICT CODE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT',EAST(1)OR MORE PERMIT APPLICATION- FORM B, SS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5.91) FORomA-S <br />