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STATE OF CALIFORNIA ° <br /> STATE WATER RESOURCES CONTROL BOARD eo: " �..'7,16 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 'itl <br /> 1 NEW PERMIT I1 5 CHANGE OF INFnRMAnnr.I T PERMANENTLY CLOSED Y SITE Bf[ O <br /> MARK ONLY 3 RENEWAL PERMIT <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PE �� IE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE C <br /> DBA OR FACILITY NAME I IdE�� <br /> ADDRESS <br /> /Jz/�;71 Tel PARCEL t(OPTIONAL) <br /> CITY NAME LV) `/ !/7 �J� �\� SITE PHONE a WITH AREA CODE <br /> ✓BOX Q CORPORATION NDMDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' <br /> TO INDICATE DISTRICTS FEDEPAUAGENCY' <br /> Homerol UST6apublbagemy.=pkle Ualollowng:wmedsW9rnso1ddvkgn,secfimoroffu Oihope2les the UST <br /> TYPE OF BUSINESS O 1 GAS STATION 0 2 DISTRIBUTOR O ✓IF INDIAN MOF TANK T SITE E.P.A I.D.N(optional) <br /> 3 FARM 4 PROCESSOR 5 OTHER RESERVATION <br /> O ORTRUSTLANDS 6 6__3g-,54:5 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME ST,FIRST) PHONE Y WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE t WITH AREA CODE <br /> Le Sd <br /> NIGHTS: NAM (LAST,FIRS „qJ PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE M WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COAIPLFTFA) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESSC (' d ✓ bc+U ntT.T'a KDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> ,e / G J j / O CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME O/ STATE ZIP CODEL, PHONE k WITH AREA CODE <br /> C J/-' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> / L <br /> MAI LING OR STREET ADDRESS ✓ bolondmis DIVIDUAL LOCAL-AGENCY <br /> GENCY <br /> 2/\ O CORPORATION = FEDERSTATEAL-AGENCY O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP ZIP CODE) T PHONE t WITH AREA CODE- <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓boXi0MInle �SELEINSURED O 2 GUARANTEE =3'INSURANCE =4 SURETY BOND 05 LETTEROFCREDR O 6 EXEMPRON =T STATE FUND <br /> Q e STATE FUND 6 CHIEF FINANCIAL OFFICER LETTER O 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM Q 99 OTHER <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: 1.0 II.E III.Lid <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT V�� <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> rL� L£ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 11 JURISDICTION# FACILITY It <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODS -OPTIONAL <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 /> FORMA(6-95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />