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s STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILITYISITE <br />I. rAlAL11 uan s. nv v, un r., ...,... <br />❑ 1 NEW PERMIT <br />❑ 3 RENEWAL PERMIT <br />❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />MARK ONLY <br />ONE ITEM <br />F_ <br />❑ 2 INTERIM PERMIT <br />❑ 4 AMENDED PERMIT <br />❑ 6 TEMPORARY SITE CLOSURE <br />e .nnoecC 1111IICT DD 1`nIIADI <br />PTFnl <br />I. rAlAL11 uan s. nv v, un r., ...,... <br />---- ---- x..- –— -- <br />COUNTY # <br />DBA OR FACILITY NAME <br />FACILITY # <br />NAME OF OPERATOR <br />�/ <br />�/.�^� <br />(Y" 1 S OLl <br />LOCATION CODE -OPTIONAL <br />CENSUS TRACT# -OPTIONAL <br />SUPVISOR-DISTRICT CODE -OPTIONAL <br />NEAREST CROSS STREET <br />PARCELY (OPTIONAL) <br />ADDRESS <br />Z�� rti• <br />a <br />STATE ZIP CODE <br />SITE PH E#WITH AREA CODE <br />CITY NAME <br />CA Z <br />3 - <br />✓ Box Q CORPORATION <br />INDIVIDUAL O PARTNERSHIP <br />Q LOCAL -AGENCY 0 COUNTY -AGENCY' <br />ED STATE -AGENCY' ED FEDERAL -AG CY' <br />TO INDICATE <br />DISTRICTS <br />' H marl UST Ls a public agency, =plate the 101bwing' name d superviaorol division, section oroNce <br />Which opennathe UST <br />TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR <br />❑ AN <br />RE EIRVATIION # OF TANKS AT SITE E.P.A. 1. D. # (aplanal) <br />❑ 3 FARM <br />❑ 4 PROCESSOR ❑ <br />5 OTHER OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) tMLHUr.N6T GUN I AU I r[naull kQ---Ie...n.1-..H..a„^• <br />DAYS: NAME( FIRST) PHONE At WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />a 5 -9 3 <br />NIGHTS: NA E (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />'5ZA?- v2 s_7 <br />D oonoDDTv nwmrP INFnRMATInN - IMUST BE COMPLETED) <br />NAME CARE OF ADDRESS INFORMATION <br />C4So�- Gv2�- <br />MAILING OR STREET ADDRESS ✓ box to iMeale [:3 INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY <br />G 6LY ED CORPORATION 0 PARTNERSHIP COUNTY -AGENCY O FEDERAL -AGENCY <br />CITY NAME STATE ZIP CODE PHyONE # WITH �ARFV CODE <br />GT _I -rrJ rGA a 9 C7 f7 'c/1) `�(52-- 2 <br />III. TANK OWNER INFORMATION - (MUST BE <br />NAME OF OWNER - <br />CARE OF ADDRESS <br />MAILING OR STREET ADDRESS ✓ boxto Atliple 0 INDIVIDUAL 0 LOCAL -AGENCY STATE AGENCY <br />/ v % O CORPORATION O PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE <br />A4oi,4A <br />-.. r11.1 l nen eTno AP_C CCC ILnMI IMT NI IMRFR. Call (9161,122-9669 If OUestions arise. <br />TY (TK) HQ 4 4- - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to lndsale 0 1 SELF-INSURED O 2 GUARANTEE O EDl� 3 INSURANCE 4 SURETYBOND ED 5 LETTEROFCREDIT 6 EXEMPTION O T STATE <br />F �­11- NNO <br />D0STATE FUND BCHIEF FINANCIAL OFFICER LETTER Q9 STATE RIND& CERTIFICATE OF DEPOSIT 010 LOCAL GOVT. MECHANISM O99OTHER <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 WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ 11. ❑ III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUEAND CORRECT <br />-ANK OWNER'S NAME (PRINTED B SIGNATURE) TANK OWNER'S TITLE GATE MONTHIDAYNEAR <br />LVVAL AUCIYI.I UOIL v11"I <br />COUNTY # <br />JURISDICTION # <br />FACILITY # <br />EE <br />2 3 <br />; s/94' <br />LOCATION CODE -OPTIONAL <br />CENSUS TRACT# -OPTIONAL <br />SUPVISOR-DISTRICT CODE -OPTIONAL <br />me l.¢nDINATInm nNl V <br />THIS FORM MUST BE ACCOMPANIED BY AI LhAb I p) ON Munc rCNIVII I Arr.l..n.n.,. - ••---- •• - -- - - -- -- --- <br />OWNER MUST FILE THIS FORTW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROITORAGE TANK REGULATIONS <br />FORMA (6-95) <br />