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STATE OF CALIFORNIA `'� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLIC 10 <br /> .5� ��( <br /> COMPLETE THIS FORM FOR EACH FACT /SITE \ Q` <br /> MARK ONLY ❑ I NEW PERMIT ❑ ] RENEWAL PERMIT ' <br /> C GE Of INFORMATION ❑ '! PERMANENTLY CLOSED <br /> ONE ITEM F72 INTERIM?ERMR -A-AMGNDEp PERMIT ❑ TEMPARYORSITE CLOSURE 10/ <br /> I. FACILITY/SITE.INFORMATION&ADDRESS•(MUST BE COMPLET <br /> OBAORFACILI E ST EOF OPERATOR. / <br /> ADDRESS <br /> NEABeSt CROSS Sf9EEi� PARCELIIOPfpNAU <br /> CITY NAME STATE ZIP CODE <br /> CA � ,���/ SITE PHONE WITH AREA CODE <br /> ✓ BOX (, <br /> TOINDICATE PoRA710N Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q OoUNrV-AGENCY $TATE AGENCY O FEDEML.AOENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN A OF TANKS AT SITE E.P.A. L D.•(q:0bW) <br /> RESERVATION <br /> $ FARM A PROCESSOR Cl 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME ST.FIRST) AV/ PHONEAWI'HOR -5: DAYS: NAM LAST,FIRST) <br /> NIGHTS! NAME( FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) A <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STRE ETADDRESS ✓ Uu ovaXor Q INDIVIDUAL = LOCAL AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PART,ERSNP Q COUNTYAGENCY Q FEOEPALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ m bllgiCAM Q INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP Q COIINTY,IGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4141-LL31 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ mNVIlraM Q I SEF-INSURED Q 2 GUARANTEE Q S INSURANCE <br /> Q 5 LETTER OF CREDIT Q a ExEMPTION Q 9P OTTER Q A SURETY SONO <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: 1.❑ IL❑ NI ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> z 2z 9 <br /> LOCAL AGENCY USE ONLY <br /> COUNT`/I JURISDICTION a FACILITY a <br /> ff7q], -Z' F77-j v <br /> LOCATION CODE 'OPT,ONAL! (CENSUS TRACTI -OP170ML $UPVLSOR- TRICT CODE .OP TpNAL <br /> O [S <br /> THIS FORM MUST BE AC MPANIED BY_ALL T(T)OR MORE PERMIT APPLICATION- F M 8,UNLESS THIS IS A CHANGE OF SIT <br /> FORM A( FORMA ONLY. <br /> SAI) F5 <br />