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•ssoVp es <br /> nue C�tiw <br /> gTkfEOrCAUFORNIA ` <br /> STATE WATER RESOURCES CDNTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA .e <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 'D <br /> I. FACILITYISITE INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> DBAORFACXITY.AIAAIEC � NAMEOFOPERATOR <br /> ADDRESS 22''AAll::l1CC,,11 NEAREST CROSS STREET PARCEL#(OPnONA0 <br /> 1413 BOURBON -qj= WEST LANE <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> SPOCK'1GN CA <br /> .1 Box <br /> TOINDCATE In CORPORATION O INDIVIDUAL [_1 PARTNERSHIP LOCAL-AGENCY E::] COUNTY-AGENCY E-1 STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR _' IF INDIAN N OF TANKS AT SITE E.P.A. I.D.x(optidbal) <br /> RESERVATIO <br /> 3 FARM Q 4 PROCESSOR ® 5 OTHER OORTRUST LAND S 1 CAT 080026362 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> EMMGENCY COMACP CINDER 510 823-7777 <br /> NIGHTS: NAME(LAST,FIRST) PHONE x WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 24 HOURS DAY SAME <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME PACIFIC BELL CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ hox bindkaU INDIVIDUAL 0LOCAL-AGENCY 0 STATE-AGENCY <br /> PO BOX 5095 RM 1 N20O ®CORPORATION I1 PARTNERSHIP Q COUNTYAGENCY Q FEDERAL AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON CA 94583-0995 415 331-0924 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> PACIFIC REL. <br /> MAILING OR STREET ADDRESS ✓ boablMmale D INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> PO BOX 5095 RM 1N20O IXXI CORPORATION I= PARTNERSHIP (]COUNTY AGENCY O FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE <br /> PHONE#WITH AREA CODE <br /> SAN RAMON CA 94583-0995 (415)331-0924 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 0 3 1 9 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boa bbdbaM I SELF-INSURED 0 2 GUARANTEE ED B INSURANCE <br /> D d SURE BONG <br /> 5 LETTER OF CREDIT 0 6IXEMPnON (] 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 I.O 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRN D8 IGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> RICHARD JOHN FACILITY ENGINEER 8/19/96 <br /> L CAL AGENCY US9.6NLY IL i\ <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION DE -OPTIONAL # <br /> (CENSUS TRACTOPTIONAL SUPVISOR-DISTRICT CODE -OPT70NAL <br /> d 00 <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 /> FORM A(5-91) <br /> FOR00ilA5 <br /> 94 Xde <br />