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4 _ <br /> f � <br /> STATEOFCAUFORMA �f '� <br /> STATE WATER RESOURCES CONTROL BOARD 3 ° <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA :e"� '. <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE �4�fanM° <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CASED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE J D <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> CITY GF Con G . U • L - <br /> ADDRESS NEAREST CROSS STREET 1 PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODEDy <br /> CA IC Z�0 fT�9� 3 3 3 AREA <br /> /,04Z7 <br /> TO INDICATE O CORPORATION Q INDIVIDUAL O PARTNERSHIP 4?!� LOCAL-AGENCY COUNTY-AGENCY' O STATE AGENCY' O FEDERAL AGENCY' <br /> DISTRICTS' <br /> N wmer al UST Is a public agency,complete the tollawirp:name of Supervkor of division,section,or o6loe which operates the UST <br /> TYPE OF BUSINESS O 1 GAS STATION ❑ 2 DISTRIBUTOR Q ✓ IF INDIAN #OFTANKSATSITE E.P.A. I.D.#Taptimal) <br /> RESERVATION <br /> 3 FARM Q 4 PROCESSOR ® 5 OTHER OR TRUST LAN DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> -1 >—Y o L0A/ <br /> MAILING OR STREET ADDRESS / ✓box b lntlicate INDIVIDUAL 11 LOCAL-AGENCY-OSTATE-AGENCY <br /> �O U CORPORATION O PARTNERSHIP D COUNTY-AGENCY FEDER4LAGENCY <br /> O <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> CA ¢meq) ;33- 6-y06 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ) 7" urs Lo,�D / <br /> MAILING OR STREET ADDRESS .1bmbindicalt D INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P. �q <br /> P 73 O 7,-CV ED CORPORATION PARTNERSHIP (]COUNTY-AGENCY (] FEDERAL AGENCY <br /> CITY NAME STATE 21 DE PHONE#WITH AREACODE <br /> Goy 04 52y�U � 1 X33 - 670 <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F4-F4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box 0lodbale [::] t SELF INSURED Q 2 GUARANTEE (] 3 INSURANCE O 4 SURETY BOND <br /> O 5 LETTEROFCREOIT =6 EXEMPTION 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ it. 111.❑: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 06 -OP16 <br /> LOCATIONCODE OPTIONAL CE7�S TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE OPTIONAL <br /> L "57-0 <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) � � FOR0033A{i7 <br />