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60JR [ I <br /> STATE OF CAUFORM sym� ea° <br /> STATE WATER RESOURCES CONTROL BOARD - o <br /> ATION-FORMA <br /> UNDERGROUND STORAGE TANK PERMIT APPLIC <br /> COMPLETETHISFORM FOR EACH FACILITYISRE T PERMANENTLY CLOSE SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 6 GRANDE OF INFORMATION ❑ <br /> MARK ONLY ❑ 4 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ <br /> 1. FACILrrytSITE INFORMATION&ADDRESS (MUST BE COMPLETED) <br /> NAMEOFOPERATOR <br /> DBA OR FACILITY NAME PARCEL#(OPTIONAL) <br /> L�r NEAREST CROSS STREET <br /> ADDRESS ODE p ITE PHO ES WITH AIR CO <br /> ZIP C <br /> ,,``L <br /> CITY NAME CA C YFEDEM4AGENCY' <br /> �0F LOCAL-AGENCY O CAUNTY-AGENCY' O STATE-AGENCY' O <br /> ./ Box l�CORPORATION ED INDIVIDUAL D PARTNERSHIP DISTRICTS' Www"the UST <br /> TO INDICATE Isle the'lolloMngl n—d Supa,'bor d dNiebn,section,or oRloe whkh aper <br /> •ry Omer d UST Is a Public egenay,mn4 ,/ IF INDIAN 40 <br /> F TAN;AT SITE E.P.A. I.O.#(aWAna11 <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORIFN RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OVER ORTFIR E LANDS optional <br /> EMERGENCY CONTACT PERSON (SECONDARY). <br /> AE 0 °PREA CODE <br /> EMERGENCY CONTACT PERSON (PRIMARY) DAYS:NAME(LAST,FIRST)PHONE#WITH AREA LADE <br /> DAYS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> //• <br /> ME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> NIGHTS: NA <br /> NIGHTS:NAME(LAST,FIRST) <br /> if. PROPERTY OWNER INFORMATION- M�USeT�Be�ErC`OMPALEETT' CARE OF ADDRESS INFORMATION <br /> NAME eA6*' �0 - ,/pox bindkala 0 INDIVIDUAL O LOCAL-AGENGY 0 STATE <br /> G r Or GST 'e <br /> MAILING OR STP ET ADD�RE�SSy�. C CORPORATION C] PARTNERSHICOUNTY-AGENCY H AREA CODE V <br /> 'r) �•-�rir- ���'F'r STATE 71P CODE v HOI <br /> CITYNNAME <br /> Lvov <br /> 111. TANK OWNER INFORMATION-(MUST BE COMPLETED) CAREOF ADDRESS INFORMATION <br /> NAME OF OWNER I — Q - LOCAL-AGENCY 0STATE'AGENCY <br /> G , G�YJ4 ✓ boxtl ndkTI 0 INDIVIDUAL 0 COUMYAGENCY O FEDERAL'AGENCY <br /> MAILING OR ST EET ADDRESS �• �„y� Q CORPORATION O PARTNFASI#P PHONE#W ITR AREA CODE <br /> / DA �'JCJ STATE ZIP CODE <br /> (/A y J� <br /> CITY NAME <br /> BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- —IDENTIFY THE USED ASOgETY SONO <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)- 3 INSURANCE <br /> D ISELF-INSURED O 6 EXEMPTION go OTHER <br /> boxtllnftate 5 LETTER OF CREDIT <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box IIf or l❑l is Chocked. <br /> L❑ <br /> CHECK ONE 80%INDICATING WINCH ABOVE ADDRESS SHOULD BE USED FORLEGALNOTIFICATNONS AND BILLING: DGE IS TRUE ANO CORRECT <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANDTO THE BEST OF My IPIOWLE DATE MONTH/DAYNFAR <br /> OWNER'S TITLE <br /> OWNERS NAME(PRINTED&SIGNED) <br /> LOCAL AGENCY USE ONLY FACILITY## <br /> COUNTY# JURISDICTION��# � _I I 1 i•lr h II I�/�/–' <br /> mCENSUS TRACT# -OP770NAL SUPVLSORpNAL <br /> -DIS11AIOT CODE�OPT�L'—Y�(�' <br /> LOCATNXN CODE -OPTIONAL Q <br /> J <br /> OR <br /> THIS FORM M OWNER MUST FILE THIS ORM WITFITTHE LOCAL AGENCY MPLEMENTING TCHE UNDERGROUND STORAGE TANr �TON <br /> K REGUULTIONS <br /> FORMA(3W) 0 <br /> 1115/9� <br />