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STATE OF CALIFORMA q <br /> STATE WATER RESOURCES CONTROL BOARD <br /> C� UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORMA _. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ! I NEW PERMIT ED <br /> 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ED 7 PE NTLY CLOSED <br /> ONE REM 2 INTERIM PERMIT O4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Tb <br /> I. FACILITYISITE INFORMATION 8 ADDRESS•(MUST BE COMPLETED) <br /> DBAORFACILITY NAM,Ep L / NAME OF OPERATOR <br /> /J✓JLp �Gt� /C[FsS !/L TG�w <br /> ADDRESS NEAREST CROSS STREET PARCEL I(OPTIONW <br /> /frs6 w <br /> CITY NAME STATE ZIP CODE SITE PHONE f WITH AREA CODE <br /> fUftis CA �S YUs' ZU 9 VG —36o 1 <br /> T�INDIICCATE ED CORPORATION CD*MOM CD PARTNERSHIP ED WMAGENCY O COUMY-AGEN6Y ED STA1E-AGENCY 't]FBIERALaBENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O i GAS STATION Q 2 DISTRIBUTOR O REI/ IF INDIAN OF <br /> SERVATION f TANKS AT SITE E.P.A L D.•(awm'MI) <br /> (� 3 FARM Q A PROCESSOR O 5 OTHER OR TRUST LAND$ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST.FIRST) PHONE f WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE F WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONc s WITP AR-A <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADORES$ J but MIFw O NAINOUAL ED LOCAL-AGENCY LJ STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP O COUNTYAGENCY r7 FEDERA4AGENCY <br /> CITY NAME STATE I ZIP CODE PHONE t WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 'e IXIF bP1EICAn Q INDIVIDUAL O LOCAL-AGENCY O STATE AGENCY <br /> ED CORPORATION PARTNERSHIP Q COUNTY-AGENCY FEDERALAGEICY <br /> CRY NAME STATE I ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 ti questions arise. <br /> TY(TK) HO 14 4 -10 1 3 a a L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓Om bYlOiMY rJ I SELF-INSURED =2 GUARANTEE 3 INSURANCE L_I A SUREttpND <br /> 5 LETTEROFCREDIT =6 EXEMPTION LI IS 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 Checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= 11.J 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY a CoT-eL /f <br /> � 1 1 P 3� <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT / OPTIONAL ISUPVISOR-DISTRICT CODE -OP <br /> ^ TIONAL <br /> VCRL7 , 9 <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("I) n� F OZ3A-5 <br /> n <br /> \� '\ty� <br />