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STATE OF CALIFORNIA 'o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ` 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> MARK ONLY <br /> ONE ITEM u 2 INTERIM PERMIT + AMENDED PERMIT 8 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BECOMPLETED) <br /> OF OP RAT <br /> DBA OR FACILITY NAME , ',.w NAM ; <br /> OR <br /> 12 r L/ NEA 11 ST CROSSREET PMCELP(OPfIONAU <br /> OGRESS <br /> ` L,JJ-y� QJ STATE ZIP E SITE PHONE#WITH AREA C-71 <br /> ODE <br /> ME / __(\ / n_ �'�}- / SSS: CA S —7 <br /> 101N BOX -C3 CORPORATION Q INDIVIDUAL ZPMTNERSINP_., � DISTRICTS CAL-AG CV CD COUNTYAGENCY 0 STATE.AGENCY O FEDEILLLaGENCY <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(OPCbnap <br /> TYPE OF BUSINESS I GAS STATION 0 2 DISTFEUTOR _ RESERVATION `/!//• - <br /> 0 G FARM Q + PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PMWRY) EMERGENCY CONTACT PERSON (SECONDARY).optional <br /> DAY�^ti Nn ME( T. ^ , <br /> PHONE*WITH AREA COOE — DAYS: NAME(LAST.FIRSn <br /> FIFISn <br /> l'IlS tet+ J 1 ap Ilo <br /> NIGHTS: NAME(LAST.FIgST) <br /> pHONE#WITHA ACODE NIGHTS: NAME(LAST,FIRSn <br /> PH <br /> . PROPERTY OWNER INFORMATION• MUST BE COMPLETEDI <br /> 1 CA EOF ADDRESS INFORMATION <br /> NAME 40 It ��c' nM l C t <br /> � box miM'rau Q INDIVIDUAL Q LOCAL-AGENCY Q STATE+IGENCY <br /> MASI ADDRESS CORPORATION � PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCYL � n1,n�K S <br /> ATE�}- ZIP CODE PHONE#WRH AREA CODE <br /> `w CITY NAME G -77/ <br /> \A\y\ III. TANK 0 ER INFORY <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWN R <br /> / ✓ w1biMicm Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> MAILING OR STREET ADDRESS <br /> Q CORPORATION a PARTNERSHIP C3 COUNTY AGENCY = FEOFFHAL+tGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST ST RAGE FEE ACCOUNT NUMBER•Cal)(916)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED supETveoxo <br /> Q 1 SELF INSURE EX <br /> O 2 GUARANTEE O ]INSURANCE l� <br /> ✓ by biblical# Q 5 LETTER OF GREW <br /> EXEMPTION Q 59OTHER <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 /> m <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHO LO BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER xVALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TOAYNEF <br /> APPLIC TSTITLE DATE/�LICANTS NAME(PANTED&SIG)1A RE; � 7� <br /> 2W <br /> LOCAL AGENC USE ONLY <br /> COUNTY# JURISOICTION# FIS 4Na3 FACILITY <br /> ® <br /> LOCATION COO OPTIONAL CENSUS TRACT s -CP TIONAL <br /> iSUPVISOR-DISTRICTC E 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 /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS �� FGRoov, <br /> � �� �n/,�,� �['�"CY//U?CJ (/YI S T ,,. .L GS�U �`�`l 3 lr/ <br /> NQLUy 1 ��,- <br />