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ssooa es <br /> STATE OF CALIFORNIA oo^ <br /> STATE WATER RESOURCES CONTROL BOARD W��, •, y <br /> rl UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ,e <br /> COMPLETE THIS FORM FOR EACH F YISITE <br /> MARK ONLY I� 1 NEW PERMIT ❑ 3 RENEWAL PERMIT E;/5"CHANGE OF INFORMATIO 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT � 4 AMENDED PERMIT E] 6 TEMPORARY SITE I URE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS G <br /> NEAREST CROSSS BET PARCEL N(OPTgNAu <br /> CITY NAME STATE IP CODE SITE PHONEN WITH AREA CODE <br /> CA <br /> T INDICATE CORPORATION Q INDIVIDUAL E:1 PARTNERSHIP LOCAL-AGEN COUNTYAGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM O 4 PROCESSOR EVr'BOTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) RGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) / iPNHONE#WITH AREA CODE I DAYS: N E(LAST,FIRST) <br /> n/004y Ax /e4> 499—ITYRE('O ? I PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I gIGS: E(LAST,FIRST) <br /> PHONE IF WITH AREA CODE <br /> II, PROPERTY OWNER INFORMATION•(MUST BE COMP ED1 <br /> NAME I [ - n ARADDRESS INFORMATION <br /> S,LA, fiG�vr. �� ✓[ /A <br /> MAILING OR STREET ADDRESS xbiiMkate =1 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> ✓ CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST'BE 0 PLET <br /> NAME OF O W NER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box biMkale 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 0 CORPORATION O PARTNERSHIP 0 COUNTY AGENCY Q FEDERAL AGENCY <br /> CITYNAME STATE ZIP CODE PHONE;WITH AREA CODE <br /> IV.BOARD OF EOUALIZA UST ORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HO � 4 <br /> V. PETROLEUM LIST FINANCIA RESPONSIBILITY (MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ box 0indicate L] 1 SELF INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> _� LETTEROFCREDIT 0 6 EXEMPTION 99 OTHER <br /> VI. LEGAL NOTIFICATIOtAATC LING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is ch ked. <br /> CHECK ONE BO%INDICATING WHDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING:THISFORMHASBEEED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED B GNATURE) APPLICANT'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USf ONLY <br /> COU TY# JURISDICTION# FACILITY# ELK5� 11 <br /> ItT.>a'IONCODE -OPTIONAL ICENSUS TRACT# -OPTIONAL ISUPVISOR-DISTRICT COD <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 /> FORM AL2 90 FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> F""` FOR0033A-R6 <br />