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STATEOFCALVORNA rr <br /> -- STATE WATER RESOURCES CONTROL BOARD e•'a-' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILrry/SrrE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 7 RENEWAL PERMIT <br /> ❑ <br /> ONE ITEM 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED 9RE <br /> ❑ 2 INTERIM PERMIT O A AMENDED PERMIT <br /> ❑ s TEMPORARY SITE CLOSURE <br /> I. FAC1LffY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> t <br /> TJ,ITYNAME <br /> /7 ���� � NAME OF OPERATOR <br /> C. I D�, CNEARESTCRO S E PMCE1alOPfpNA{JVc ZSITEPFIONEiWITH AREq CODE <br /> ao <br /> TE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOM4GENCYCWNfYAGENCY'STlaa Wblit a 06TRCi3' QSTATE-AGENCY- QFEDERALAGE4CYag n y.ox 10'Ihs IoIIoYMg:na d SuP mw d dNYbn,wabn,oroNloMild)� mm Ihs UST <br /> INESS O OAS STATION ❑ 2 OISTRIBUTOR ❑ ✓ IF INDIAN s OF TANKS AT SITE E.P.0. <br /> S FAgM RESERVATION / (RotAmie <br /> Q Q a PROCESSOR S OTHER OR TRUSTLANOS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optimal <br /> DAYS: NAME(LAST,FIRS PHONE i WITH AREA CODE GAYS: NAME(LAST,FIRS <br /> ,S o, �S 5r n PHONE i WITH AREA CODE <br /> NIGHTS. AME(WT,FIRST) PHON a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHCNE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> + NAME CARE OF ADDRESS INFORMATION <br /> glui*kq <br /> MAILING�OAR E•-,ADORESS ✓me bvbbYa Q INDIVIDUAL Q LOCALAGaCY Q STATEAGENCY <br /> •d' / D� CORPoRAnON Q PARTNERSHIP Q COUNTYAGENcy Q FEOERIL#GENCY <br /> CITY. E STA LP COpE D pH0 E a Wl AREA <br /> v�rllbr'� Y/T[o3 s7=� iT <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NA -OF0 4 /'1 CARE OF AOCRESS INFORMATION <br /> CM;ATIYparOIERITALD-QO_RE ✓ m.b WQ INDIVIDUAL LOCAL-AGENCY STATE AGENCY <br /> INCORPOON Q PARTNERSHIP COUNTYAGENCY FEDERAL-AGENCY CYO. AREA CODESTAjZP CODE <br /> �SO W <br /> �b, S <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(9166))322-9669 if questions arise. <br /> TY(TK) HQ F4747- <br /> V. <br /> 4- -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> J ma brdFals Q I SELF-INSURED 2 GUARANTEE Q 7 INSURANCE Q A SURETY BOND <br /> 0 5 LETTEROFCREDR Q S EXEMPTION Q N OTHEq <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 VOUCH A80VE AD `ESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L IL❑ III.❑ <br /> THIS FORM HAS BEEN COMP ED UNDER PENALTY OF PERJURY,AND TO THE BEST CFAIY KNOWLEDGE,IS TRUEANO CORRECT <br /> Owl,ERS NAM (PRINlED¢SI D) OW ERS TfTL DATE MCNTWOAYNEAR <br /> LOCAL AGENCY USE ONL <br /> COUNTY a JURISOICTCN s ( FACILITY i <br /> m � ILII <br /> — LOCATION CODE -OPTIONAL CENSUS TRACTs -OPTIONAL SLAVISOR•OISTRICT CODE •OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY ST(1)OR MORE PERMR APPLICATION- FORM BI UI ITHLS B A CHANGE OF SITE INIFORMATION ONLY. <br /> OWNER MUST PILE THIS FC� ING.ITH THE LOCAL AGENCY WLEIENTTHE W)SGIMXkii D STORAGE TANK REGULATIONS <br /> FOPL A 13i90) FORDUMHU <br />