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STATE OF CAUFOPJAA <br /> ATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FOR;'.', A10, /,z-7BY <br /> Y/F,V <br /> C <br /> v COMPLETE THIS FORM FOR EACH FA ;SITE <br /> MARK ONLY/,j,_: <br /> PERMIT II 3 RENEWAL PERMIT IJ CHANGE OF INFORMATION 7 PERMANENTLY CLOS- i7 F <br /> CAE ITEM/ <br /> 2 TERIxI PERMIT a AMENDED PERMIT I e Tc VPORARY SITE CLOSURE O !/ <br /> I. FACILITxci�.U- FORMATION& ADDRESS•(MUST BE OMPL ) <br /> JEA CR FACiLITV NAME ME OF OPERATOR <br /> ADDRESS y I NEAREST CROSS STREET I PARCEL.(OPTIONAL) <br /> CITY.vA•AE 6W/ i STATE 121P COOED. / SITE PHO�—�WIT14 AREA D <br /> CA S 6 Y <br /> J Wx `CCRPORATAN Q IN .- PARTNERSWP L_=4 AGENCY Q OOUNrYAOENCY C STATE AGENCY [=' FEDERAL-AGENCY <br /> To INOCATE — If DISTRICTS <br /> TYPE CF BUSINESS t GAS STATION2 DISTRIBUTOR rr-�-I J IF INDIAN •CF TANKS AT SITE E.P.A. L D.•IOP1Nam) <br /> 'J L—= ` RESERVATION n/ <br /> L 3 ;ARM (^ A PROCESSCR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE.WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> 0 <br /> NIGHTS: NAME(LAST.FIRST) PHONE.WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> Rur c.'APTH AMC Ar c <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME I CARE OF ADDRESS INFORMATION <br /> MA;LC.G OR STREET ADDRESS ✓ Omamca. Q INDIVIDUAL C LOCAL.AGENCY ` STAIo-AGENCY <br /> n CORPORATION C_7 PARTNEASHP G' COUNTY.IGENCY FECEAA440ENCY <br /> C;TY NAME I STATE (LP CODE I PHONE.WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ ».am = INOVOUAL G LOCA44GENCY (_,J STATE-AGENCY <br /> J CORPORATON O PARTNERSHIP Q CoUNTY.AGE.NCY Q FEDERAL•AGEICY <br /> CITY NAME I STATE I ZIP CODE I PHONE.WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 it questions arise. <br /> TY(TK) HQ F4-1-47,-���—� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> J Iq.RNGY L_ I SELF+NSURED LJ 2 GUARANTEE 1 WSUAANCE Q .SURETY aONO <br /> L 5 IETTERCFCREDT ri 6 EXEW MN (_) N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and blfing 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 BR.LNM L= IL= RL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLA:A rs NAME(PANTED&SIGNATURE) APPLICANT'S TITLE OATS MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY P JURISDICTION a FACILITY a <br /> �qftSjml a <br /> LOCATIONCODE •OPTIONACENSUS TOO6 OPTIONAL SUPVISOISTRICT E •OPTIONALIGG RDz <br /> THIS FORM MUST BIt ACCOMPANIED BY AT LEAST(I)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FOAM A("I) �$eA=3A.5 <br />