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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a_ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - PORIA A W�� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> ii MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION �/f,,PE_'FIJMANENT+�SED SITE <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME / / NAME OF OPERATOR + <br /> ADDRESS NEAREST CROSS STREET PTIONk) <br /> CITY NAME STATE ZIP CODE TE PHONE#WITH AREA CODE <br /> CABOX N <br /> ai - —�3�/�❑ <br /> TOINDCATE CORPORATION Q INDIVIDUAL Q PA4RSHIP LOCAL-AGENCY COUNTY-Ah Y (] STATE-A ENCY 0 FEDERAL-AGENCY j <br /> DISTRICTS F <br /> .TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN # FETA KS AT TE E.P.A. 1.D.#(optional} <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY NTACT PERSON (SE ONDARY)•optional <br /> I� DAY NAME AST,FIRST) PHONE# ITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> +I <br /> NIGHTS: NAME(LAST,FI ST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE I # <br /> WITH AR E6 CQQE <br /> j 11. PROPERTY OWNER INFORMATION---(MUST BE COMPLETED <br /> NAME ►� (y / CARE OF ADDRESS INFORMATION <br /> I F_2 A C/b( <br /> I <br /> MAILING OR STREET ADDRESS p ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> 15 16 0 <,z /Til L =CORPORATION PARTNERSHIP [] COUNTY-AGENCY FEDERALAGENCY p <br /> CITY NAME STATE ZIP CODE PHONE WITH REA CODE i <br /> � �3's 7 �-t� _ r3C 7 <br /> f III. TANK OWNER INFORMATION•(MUST BE COMPL TED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> l i <br /> l MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> p� ©CORPORATION PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY x <br /> CITY NAME STATE ZIP CODE PHONE#WIT44 AREA CODE r <br /> 1V.BOARD OF ECIALIZATION UST STOR GE FEE A COUNT NUMBER-Call(916)323-9555 if questions arise. L <br /> TY(TK) HQ4 - D UY+ Z <br /> V. PETROLEUM UST NCIAL RESPO TY-(MUST BE COMPLETED)-IDENTIFYt-TFiE-METHO'D�S) SED <br /> ✓boa n indicate 0 t SELF-INSURED []2 GUARANTEE CI 3 INSURANCE 4 SURETY BONA <br /> I © 5 LETTER OF CREDIT ©6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box i or 11 is c cked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY CSC PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE E�— MONTI/DAYNEAR <br /> s <br /> v7 -9 v I <br /> LOCAL AGENCY USE ONLY <br /> COU�NTY�# L, � LJ JURISDICTION# FACILITY# <br /> `--Z ' I' I <br /> LOCATION CODE •OPTIONAL (CENSUS TRACT# -ITrb SUPVISOR DISTRICT CODE - TIONAL + <br /> THIS FORM MUST Bt AICCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS INFORMATION ONLY. <br /> FC RM A(5.91) FOR0033A-5 <br /> I <br />