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'UyOUo <br /> STATE OF CALIFORNIA c <br /> 0 <br /> —� - STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE o�„a,„,• <br /> MARK ONLY O d NEW PERMIT L�j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 9'17>E <br /> ONE ITEM 0 2 INTERIM PERMIT 04 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE Sv <br /> I. FACILITY/SITE INFORMATION$ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Co. S . r u �—i0h <br /> ADORE NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> e1Y, GIV/ <br /> CITY NAME STATE ZIP CODE SITE PHONE a WI7H AREA CODE <br /> S IC -CA <br /> TINDICATE I�CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP I�I�wT -Ag NCY ��MYAGENCY• Q STATE AGENCY' Q FEDERLLAGENCY' <br /> If owner d UST la a public agency,cor piste the follovAl nave W Supervisor of divbbn.section,or office which operates the UST <br /> TYPE OF BUSINESS F__j t GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A I.D.#(optional/ <br /> flESERVATIO <br /> Q 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optional <br /> DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE if WITH AREA CODE NM14TS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> k e-S <br /> MAILING O�flI <br /> yTR TADDRESS ,,//�� ✓Ea bkdco INDIVIDUAL = LOCAL AGENCY 0 STATE-AGENCY <br /> L Z--S f3ad,4 CORPORATION I3 PARTNERSHIP = COUNTYAGENCY E:1 FEDERAL-AGENCY <br /> CITU NAME - ITATE ZIP CODE PHONE a WITH AREA CODE <br /> Cmc SZj Z— <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bubindicW INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> D CORPORATION O PARTNERSHIP COUNTY AGENCY FEDERALAGENCY <br /> CITY NAME STATE ZIPCODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUSTBECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ borbiMicaie 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT O e EXEMPTION Q 0 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: L= N.D IN.O v� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT V� <br /> OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# O <br /> ® s6Q FACILFTY# - - <br /> 0 i� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a .OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOReW31A7 <br />