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ECEIVED <br /> OUA f CO <br /> ` STATE OF CALIFORNIA y"e"��� `. <br /> STATE WATER RESOURCES CONTROL BOARD w��, - <br /> UtQ.1�T�Ii?�IU�0�TO RAGE TANK PERMIT APPLICATION - FORMA u: <br /> ENVIRONMENTAL HEALTH (V01�„.. <br /> PERM LETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY u I NEW PERMIT FI 3 RENEWAL PERMIT X <br /> 5 CHANGE OF INFORMATION F_] T PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE S <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 06AOR FACILITY NAME NAMEO OPERATOR <br /> _ R rte' _ <br /> AD S x NEARES`C OSS STREET PATiCELp(OPTIONAL) <br /> C N ME FAY — S CA IP COO��© � SITE PHONE%WITH AREA CODE <br /> TO INDICATE D CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION 2 DISTRIBUTOR RES/ IF INDIAN <br /> ERVATION %OF TANKS AT SITE E.P.A. LD.%(opfiwap <br /> O 3 FARM 4 PROCESSOR X5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) j PHONE# TH ARE CO E DAYS: NAME(LAST,FIRST) <br /> PHONE*WITH AREA rnnP <br /> N HT 7 (LAST, IRSTj� PHONE# IT AREACO E NIGHTS: AME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORM ON-(MUST BE COMPLETED) <br /> NAME CARE OF ADD SS INFORMATION <br /> MAILING OR STREET ✓ box bindieale INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY O FEDEML-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMP TED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ IiPW!rLlcele Q INDIVIDUAL OAL-AGENCY [� STATE AGENCY <br /> CORPORATION1 PARTNERSHIP Q COU -AGENCY 0 FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE ITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L 4�- _]= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box mindicate 0 I SELF INSURED =2 GUARANTEE 3�IBURANCE 4 SURETY BOND <br /> C 5 LEITEROFCREDIT =6 EXEMPTION W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to thetank owner unless box I or II is checked. <br /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ U.E] U. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY•# JURISDICTION# FACILITY# <br /> j , / i F[ ___6n� /�I�� P <br /> LOCATIONCO OPTIONAL CENSUS T# -OPT NA SUPVISOR-DISTRICT CODE -OPTIONAL <br /> L <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 A(Iz-9n FILE THIS FORM WITH THE LOCAL AGENCY Ih1PLEMENTINGTHE UNDERGROUND STORAGETANKREGULATIONS <br /> FORW33A-R6 <br />