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STATE OF CALIFORNIA •�•o,.• < <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FOR _ <br /> • Y <br /> COMPLETE THIS FORM FOR EACH F <br /> LITY/SITE - <br /> FMARK ONLY ❑ 1 NEW PERMIT DI RENEWAL PERMITE!i < <br /> ONE ITEM 5 CHANGE OF INFORMATIONPEA NENTLY <br /> 2 INTERIM PERMIT [—] A AMENDED PERMIT RE <br /> ❑ 6 TEMPORARY SITE CLOSURE CU' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ✓ / <br /> DBA OR FACILITY NAME <br /> (�..(/ <br /> _ /� / �� NAME OF OPERATOR <br /> ADDRESS J (i( J <br /> NEARESTCgOS$$TREET PARCEL#(OPTONAU <br /> CITY NAME 7/ <br /> STATE ZIP COp�' I, SITE PH NE WITH DIE <br /> si CA 9 <br /> ✓ Box G d z= 7 <br /> TOINDICATE CORPORATION C INDIVIDUAL Q PAATNERSMP p LOCAL-AGENCY <br /> 0STRICTS 0 COUNTY#OENCY I� STATE-AGENCY C FEDERAL#GENCY <br /> TYPE OF aUSINESS I GAS STATION <br /> ❑ ❑ 2 DISTRIBUTOR ✓ IF INDIAN s OF TANK$AT SITE E.P,q. L p,•(Ppply <br /> ❑ OR <br /> ❑ O FARM A PROCESSOR 5 OTHER RESERVATION 1 <br /> TRUST LAND$ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE 6 WITH AREA CODE <br /> DAYS: NAME(LAST,Flq$1) <br /> NIGHTS: NAME(LAST,FIRST) PHONE/WITH AREA CODE <br /> NIGHT$: NAME(LAST,FIR5T1 <br /> II. PROPERTY OWNER INFORMATION•fMUST BE COMPLETED oW RFA^ <br /> NAME <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADCRES$ <br /> ✓ 5otp � C INDIVIDUAL J LOCAL-AGENCY L STATE-AGENCY <br /> Cltt NAME L1 CORPORATION C PARTNERSHIP C COUNrY#GENCY C FEDEAALAGENCY <br /> II ZIP CODE I PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) STATE <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> MAILING Oq STREET AppgESS <br /> ✓ oo�P`wc� 0 INDNWK C LOCAL.AGENCY C STATE-AGENCY <br /> CITY NAME I O CORPORATION Q PARTNERSHp Q COUNrY#GENGy Q FEDERAL#GENCY <br /> STATE I LP CODE PHONE s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if quest <br /> TY(TK) HQ 4 4 - 2 I r2 O Iff <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <m oigky <br /> ff 1 SELFIREDRED <br /> O 5 LETTER OFCRECrr 2 GUARAN EE C ] 6 SURANCE <br /> C 6 EXEMPrgN 099 OTHER Q 1 SURETY BONO <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or His checked, <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLNG: <br /> 1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY PERJURY,AND TO'THE BEST MY KN ❑ IL❑ MIL❑ <br /> APPL�CANrs NAME(PRwiED a SIGNATURE) OWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION <br /> FACILITYr <br /> LOCATION CODE -OPTIO (CENSUS TAT -Op 7,y1µ / <br /> SUPVI$Oq•L <br /> FORMA(5911 p1STRIGT CODE -CPTp/JAL <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 /> FOROO75A5 <br />