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A <br /> J STATE OF CAUFOWAA i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> �, . <br /> —` COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY O 1 NEW PERMIT a 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ] PERMANENTLY 0. USRE-'!'�- <br /> `3: <br /> ONE ITEM 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE t <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA[IaClff NAME NAME OF OPERATOR <br /> or e- ct /� .b, /to- NEARESTCROSS STREET PARCEL(OPfgNAL) <br /> ADOREIt E , Il.1/f <br /> CITVSl � STATE ZIP ODE SITE PHONE S WITH AREACODE <br /> iC1J--7t(gI CA ✓ <br /> ./ BOXTE -:- CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-DISTRI <br /> AGENCY C3 COUNTY-AGENCY O STATE-AGENCY 0 FEDERALAGENCY <br /> TOINDI <br /> TYPE OF BUSINESS Q T GAS STATION Q 2 DISTRIBUTOR 0 gESERVA�ION IAN A OF TAfJ({S AT SITE E.P.A. L D.x(aptimW) <br /> Q 3 FARM Q A PROCESSOR = 5 OTHER OR TRUST LANDS `jJ( <br /> EMERGENCY CONTACT PERSON (PRIMARY) - EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) ' <br /> NIGHTS: NAME(LAST.FIRST) PHONE x WITH AREA COOS NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME <br /> ✓ Imbiwi 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> 0 CORPORATION D PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL#GENCY <br /> STATE ZIP CODE PHONE x WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ✓ bo3WME 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY.: <br /> MAILING OR STREET ADDRESS <br /> 0 CORPORATION O PARTNERSHIP OCOUNTY-AGENCY O fETIEML#GENCY ' <br /> STATE 21P CODEP HONE x WITH AREA CODE - <br /> CITY NAME <br /> IV.BOARD OF EQUALIZrA�TION US�T STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 -L J <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY fUSTI COMPLETED)—IDENTIFY THE METHOD(S) USED A SURD <br /> 0 1 SELF-INSURED <br /> O=GUARAMEE 0 7 INSURANCE O <br /> ✓ bm bWtl 0 6 EXEMPTION 0 99 OTHER <br /> 0 51ETTEROFCREDIT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. 'Y <br /> L= IL= -, Nl.❑ <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: -, <br /> CT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IDS TRUE AND ON HIDAENEAR - <br /> APPLICANTS TITLE <br /> _.. <br /> APPLICANTS NAME(PR WTE0851GNATURE) <br /> LOCAL AGENCY USE ONLY 3 <br /> JURISDICTION# FACILITY <br /> � <br /> Co® 4q� <br /> CENSUST ACTx - TONAL SUPVISODI T „0,.OPTIONAL <br /> LOCATION�OLjE -OPTIONAL �� , P�(J �a a . ( <br /> THIS FORM MUST BE ACCOMPANIED OT At LEAST(QT)OR MORE PERMIT APPLICATION. FORM ,UNLESS THIS IS A CHANGE OF SITE INFOflMAT10 ONLY �[r <br /> FORM A(5-91) <br />