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L= <br />STATE OF CALIFORNIA a STATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ACOMPLETE THIS FORM FOR EACH FACILMTYISITE <br />MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br />ONE REM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT <br />Q S TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION A Anntaecc _ fast ler ee _. <br />DBA OR FACILITY NAME <br />ADDRESS <br />NAMEOFOPERATOR <br />qp0�/G V/GTGye �OQ� <br />NIGHTS: NAME (LAST, FIRST) PHONE •WITH AREA CODE <br />IN ARE TREET <br />PARCELe(OPIONAU <br />CITY NAME <br />�Q <br />STATE ZIP CODE <br />CA 9BOX SZy/ <br />SITE PHONE a WITH AREA CODE <br />TOINDICATE CORPORATION Q INDIVIDUAL PARTNERSHIP <br />Q LOCAL -AGENCY ED COUNTY -AGENCY' <br />—W�' <br />Q STATE -AGENCY FEDFJML.ABENCY. <br />' N owner d UST Is a public agency, oonWMe the DISTRICTS' <br />Ldbwkp: nanla of SuPervbor of division. eecliOn, or Of ice <br />TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTRIBUTOR✓ <br />which operal" the UST <br />IF INDIAN s OFT <br />O <br />AT SITE E. P. A. I. D. <br />RESERVATION <br />Q 3 FARM Q 4 PROCESSOR 5 OTHER 1. <br />a (pohm NJ <br />OR TRUST LANDS <br />DAYS: NAME (LAST, FIRST) PHONE a WITH AREA CODE <br />...... T WNI AV] PtHSUN (SECONDARY)• optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE a WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE •WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE a WITH AREA CODE <br />n. rnVraniIUVVNCMINrUNMA[JUN- INFORMATION BE COMPLETED <br />NAME <br />� CARE OF ADDRESS INFORMATN <br />MAILING OR STREET ADDRESS - ✓ .P .Inekile L—J INDIVIDUAL =1 LOCAL -AGENCY 0 STATE -AGENCY <br />v • <br />CITU NAME Z %a)CORPORATION = PARTNERSHIP = COUNTV-AMNCY O FEDERALAMNCY <br />-- <br />WITH <br />STATE ZIP a -9m AREA <br />2y7 <br />LoGy (5114 �D <br />OF ADDRESS <br />-- <br />t.T1 <br />U INDIVIDUAL Q LOCAL -AGENCY 0 STATE-ADENCY <br />/Z7oPORATIO!PARTNFASHIP O CWN Y#GENCY Q FEOEMLAGENCY <br />ZIP CODE HONE + WITH AREACODE <br />64 Z 2tJ �6f <br />•-•--�••••- .....rvr.v.a..ArvnnV�r�c AAwvulvt Numoen-uau I9TD)JZY-91ifi91t Question arise. <br />TY (TK) HO F414--] - �❑ <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br />•� Em NhlRcau I11 SELF-INSURED Q 2 GUARANTEE O 3 INSURANCE O 4 SURETYBONO <br />E71 5 LETTEROFCREOIr l= 6 EXEMPTION E-1 >N 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 />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.�e III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />VwnL nV LtaY. voo VIVLT <br />COUNTY # JURISDICTION # FACILITY # <br />❑ I �/ 7 CiZ✓,�q� <br />LOCATION CODS-OPTA7A/AL CENSUS TRACTa-mTtlAul ciiwieno-nio.oi�+,...,.� .. <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - <br />B, UNLESS THIS is A CHANGE <br />FORM A fffi931 vwNLK MUS I rILG I HIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />