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P cyn <br /> STATE OF CALIFORNIA _ 'o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA ?P o <br /> COMPLETETHIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ � PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Jr3 <br /> I. FACILITY)31TE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME, FOPEflATOR <br /> OBAORFACILITYNAME <br /> 19 A41 <br /> NG NE RESTC SS STREET PARCEL#(OPTK1NAq <br /> ADDRESS D B C L � <br /> STATE l� ZI CODE SITE PHONE#WITH AREA CODE <br /> CITY NAME <br /> CA Ogr7 77,r <br /> TO INDBox ICATE O CORPORATION (] INDIVI AL I]PARTNERSHIP 0 LOCAL-AGENCY I�COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> ❑ 1 GAS STATION 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(opfianal) <br /> TYPE OF BUSIN SS <br /> RESERVATION <br /> O 3 FARM O 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(L)ST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> PHONE I WITH AREA nnni; <br /> NIGHTS:NAME LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE DDRESS INFORMATION <br /> NAME <br /> nr� roL N <br /> ✓ box blMk INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> MAILIN QRST EETADDRESS i nJs <br /> �• x �CORPORATION O PARTNERSHIP �COUNTY l� FEDERAL-AGENCY <br /> STA p <br /> ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME /��3' <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> EEW'9N R <br /> ✓ boxbirdkaleREET ADDRESS O INDIVIDUAL 0LOCAL-AGENCY STATEAGENCY <br /> 0 CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDERALdGENOY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) 0 4 4 3 ,Z 2 <br /> V. PETRC LEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I SELF-INSURED 0 GUARANTEE ``)) ,, F] 3 INSURANCE 04 SURETY BOND <br /> ✓ box binEic 0 5 LETTEROFCREDIT EXEMPTION(_j�p- 0 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 griecked. <br /> CHECK ONE X INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II. III. <br /> THI FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S AME_(PRINTED B SIGNATURE) <br /> APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL A SENCY USE ONLY <br /> COUNTY# JURISDICTION# � FACIILITYY#�-�-,-�# <br /> rn I I/�1� 114M-Mh 70 <br /> 7 e-#- j <br /> EL4z <br /> DE -OPTION-AIL—� CENSUS TRACT# -OPTIONAL SUPVISORR�S$RICT CODE -OPTIONAL <br /> z 3, go <br /> THIS FO M MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. J <br /> FORM A(5-91) <br />