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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W��� m <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA .P - , <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE w <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT M5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB OR FACILITY AME NAME OF OPERATOR G n <br /> Is <br /> ADDRESS NEAREST CROSS STREET / PAWRCCEL##(OPPTITI`-IONNAALL) <br /> I I Lm ivJl <br /> CITY IIIAMESfATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CJ/f�'K (/tet/.•#f/_Y_v. CA <br /> ✓ BOX 0 CORPORATION 0 INDIVIDUAL [�j PARTNERSHIPLOCAL-AGENCY O COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE A,DISTRICTS <br /> X ownercl USi H a public ageri complete the following:name d supenhwirofdM ,sextan or office whidwpertles the UST <br /> TYPE OF BUSINESS ❑ t GAS STATION ❑ 2 DISTRIBUTOR = pE5E1IF INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM O # PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NA E( ST,FIRST) PHONE#WITH AREA CODEDAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> .7 a v <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE If WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S avw cw s-r7 <br /> MAILING OR STREET ADDRESS ✓ box to oxi Q INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 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 ✓ bextoeMicate ED INDIVIDUAL O LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION = PARTNERSHIP Q COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HO F4-[4--] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓110 in&rat# At SELF-INSURED f� 2 GUARANTEE 0 3 INSURANCE O#SURETY BOND f�5 LETEAOFCREDIT 0 6 EXEMPTION O 7 STATEFUND <br /> 08 EFUNDECHIEf FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT [::] 10 LOCAL GOVT.MECHANISM E-1 99 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: 1.❑ II.❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNERS TITLE DATE MONTHiDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> � <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <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 /> FORMA(6-95) <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGR*STORAGE TANK REGULATIONS <br /> - <br />