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• STATE OF CAL:FCRNA • :r""' fes;•`L <br /> STAiE'AATER RESOURCES CONTROL BOARD sPSN""?�>'+" : <br /> UNDERGROUND STORAGE TANK PERMIT APPLIC ,/\1/�/jJ/\/q' <br /> COMPLETE THIS FORM FOR EACH F ,,rYlStTE v �� •• <br /> .MARK ONLY L_ I .NEW PERMIT S RENEWAL PSAMIT J S CHANGE OF INFCPMA'CN j_ 7 ]ERMANEN TLV CLOS'c0 SPc <br /> CNE iTEM 1 7ri.VTEajM ?E,_ R __MIT I_ A AMENCED PERMIT I a .cVPOE CLO <br /> RARY SITSURE /, 1 <br /> �•` / <br /> I, FACIL",'SITE INFORMA71ON 3 ADDRESS•(MUST BE COMPCE EO) <br /> CdA CR%+C.U�rN <br /> .• <br /> 71-m <br /> _ AM£OF CPEAATOR <br /> le <br /> ACCRESS t ,T- ?�,, 5-QC-- NEAREST CRC STREET I 7ARCEL rICPICNAU <br /> ;:'Y.va•.;E TI STATE ( ZIP COCE i SITE'ICNE.WITH AREA CCCE <br /> SBOX CA <br /> 'C OCAiE 'Q ccAmPAI.CN CUAL PWTAE'.SWPj L=ALAOENCY Q CCUNTY.IGENCY C STAniAGecy Q FFCERALAGENCY <br /> tt?E OF 31SINESS I GAS STATION l_ $ CISTRIaUTCA I J '.F.NCIAN A OF TANKS AT SIrE E.P.A. L D..Iaala+Aa <br /> RESERVATION <br /> S :ARM A PROCZSSCR 5 OTHER OR,RUST LANCS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•apdanal <br /> DAYS: NAME LUST,FIRST) PHONE.' TH AREA CCCE DAYS' NAME kLtST,FIRST) <br /> /ItjCos - ` 8' 6rr4la <br /> .VIf,NE(LAST.FIRS, PLANE.WITH AREA COCE NIGHTS: NAME(LAST.FIRSTV <br /> aw c.•r�T-I AacA��re <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME / it I CARE OF AOCRESS WFORMATICN <br /> VAiL.t.G OR STAEET AZORES �'7 ) �, J b..t IQ INUVICU,LL Q LOGO-ACDOCY ` S Am-ACEYCY <br /> I VIN'D U Q CCP CRA GN Q P41TNE S aP `CWMY ACc{ Q SE AIZCY <br /> C:Tf.vA.uE ` I STATE ILP -/ HCNE.w1T�1=REA <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME CF OWNER ,/ _ n / CARE OF ACCRESS INFORmAnCN <br /> l///V// ,U�Cn6 t <br /> VAILNG OR STREET AOCRESS J mamcPa <br /> IQ uXXYoux L=; Locx4cF.rcr Q rar.AGENCY <br /> Q CCRPCRASION Q PART*RSWP Q CCUNrY.AF.NCY Q FECERLLAGENCY <br /> C:^r NAME I STATE I LP CCCE I PHCNE I WITH AREA COCE <br /> IV.BOARD OF EOUALRATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 it questions arise. <br /> TY(TK) HO F4-147,_1,177771 605 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOO(S) USED <br /> J!m a.NNa. lam_. I SEWNSYRED Q 7 GUARANTEi Q S 9SURANC'a Q 1 9A 30M0 <br /> Q S LFTf-vI OF CREW Q 1]IEWIK7N Q 3a CTf<R <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal nctir"ion and billing ml be sent to the tank owner unless box I or IL's checked. <br /> CHECX ONE 3OX NCCAT'Jq wHCH AaOVE ACORESS SHOULD 9E USED FOR LEGAL NOTIG',CATIONS AND QI LNG: L= IL® ILL <br /> THIS FORM HAS BEEN COAdPLEi EO UNDER PENALTYCF PERJURY,AND TO THE BEST CF MY KNCN2EOGE.is TRUE AND CORRECT <br /> APPL.UNT$NAME kPRAMED A SIGNATURE) AFP,-cANTS TITLE DA_1C MONTWGAYNEAR <br /> ,o-36,yZ <br /> LOCAL AGENCY USE ONLY /f- <br /> COUNTY a JUR)SOICTION 8 FACVTY a <br /> a�] Mcv-r'/✓oi �� <br /> UCCATCNCCCE -OPTIONAL (CENSUS TRACT. CPn,7 I OR SUIS •OLSTRCTCCCE •WnCNAL <br /> (� OV ,9- <br /> THIS?CRM!RUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SYE INFORMATION ONLY. <br /> FORM A(5.91( FCR=Z $ <br />