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ST ATE OF CAL:FCSMA • �'. <br /> S I a NATER RESCURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORS:; A <br /> COMPLETE THIS FORM FOR EACH' CIRYISITE <br /> MARK ONLY I NEW PERMIT _i_3_ACNe#AL PSAM1T 5 CHANGE CF !NFCRMATICN 'h 7 PERMANENTLY CLOSEO SITE <br /> C':E ITEM 2 :NT-c:IM ?EAMIT s .WENDED aEaM1T�.�_-�._�I..-g �F"�.1PORAAY SITE CLOSURE D <br /> I. FACLITYISITE INFORMATION & ADDRESS•(FAUST BE COMPLE ED) <br /> :,dAJR:AC:u7YNAME S� Cif- ? 1 NAMECFCPE.ATOR <br /> 1 <br /> ACCRcSSI NEARESTCRCSSSTREET I PARCEL#(OPTIONAL) <br /> 13z <br /> C:TY NAu I STATE ZIP COCE SITE PHONE s WITH AREA CODE <br /> % s I CA <br /> TO GOATS Q CCRPORAT:ON I Q A01VICUAL Q PARTNERSWP Q WCAL•AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FOERAL-AGENCY <br /> OtSTRICTS ___ <br /> ?5 CF 3USINESS t GAS STATION = 2 OISTR:dUTOR Q ✓ '•F NCIAN IaCF TANKS`AT SITE P.A L 0.s M-WWall <br /> RESERVATION _ <br /> RA ci3OR 77 5 OTI-ER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) - EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> LAYS: NAME{LAST,FIRST) PHONEI'NITHFAREA CODE DAYS: NAME1LAST <br /> ,FlfiSn �y,D�✓a�����// <br /> TS: NAME(LAST,FIRS PHONE•WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> � our c!p�Tu AacA r^rc <br /> II. PR — OWNER INFORMATION•(MUST BE COMPLETED) <br /> NXJE ___ - I CASE OF.ADCAM AFORMATICN <br /> UXLIt.G CR STREET ADDRESS ✓ W1 arwcm IQ INo1YCUAL Q LOCAL-AGaNCY Q 3TArZ-AGENCY <br /> I r CCRPCRATION Q PARTNERSWP `;COUNTY-AGENCY Q F—tCVUL•AGENCY <br /> C;TY NAME STA I c I ZIP COCE I PHCNE s WITH AREA CCCE <br /> III. TANK OWNER INFORMATION-(MUSTS E COMPL-TED) <br /> NAME OF OWNER CARE OF AGGRESS INFORMAT.CN <br /> .MAIL:NG CR STREc7AOORESS ✓ =anacm Q lfavcuA Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSMP Q1 COUNTY-AGENCY Q FEDERAL AGENCY <br /> C:TY NAME I STATE I ZIP CODE I PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 it questions arise. <br /> TY(TK) HQ 4 4 -1 0 1 Z&11� l • <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓�otar+�caa Q I SELF-INSURED L 2 GUARMITEE L 3 JSURAI4CE Q A SURETYaONo <br /> n s LErr:-a OF cma Q 6 EXEWMON Q 99 DTFIER <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 3OX INDICATING WHC;H ABOVE ADDRESS SHOULD aE USED FOR LEGAL NOTIFICATIONS AND BILLING: L= IL= IIL n <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE.IS TRUE AND CORRECT <br /> APPLICANT'SNAME(PRWicOISIGNATURE) APPL,CANT'STITLE DATE MONTWOAYNEAA <br /> -Z <br /> LOCAL AGENCY USE ONLY jam/ <br /> COUNTY x JURISDICTION s FACLITY A <br /> LOCATION COCE -GPrIONAL (CENSUS TA ACT 0 •Of nONAL sUPVISOR-DISTRICT COD CPr1UNAL <br /> THIS FCRM.`BUST 9E ACCOMPANIED 9Y AATTTLLEEASOT((i))OR MORE PERMIT APPLICATION• FORM S,UNLESS THIS IS A CHANGE OF SRE INFORMATION ONLY. <br /> EC RM A(5 a t) + FCRo='5 <br /> Al/I <br />