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STATE OF CALIFORNIA °- <br /> OTE WATER RESOURCES CONTROL BOARD <br /> W <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORM) A <br /> COMPLETE THIS FORM FOR EACH FACIL5Y,SITE <br /> MARK ONLY I NEW PEAM4T 3 RENEWAL PERMIT 7-I 5 CHANGE OF INFORMATION r^ 7 PERMANENTLY <br /> V IE ITE'd 1-1 2 iNTE.RIM PERMIT Is A AMENDED PEPMIT i 8 TEMPORARY SITE, CLOSURE � J <br /> 1. FACILITY,SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> OiaA-R;ACILITY NAME„ �� NAME OF OPERATOR <br /> AceAEss <br /> / . NEAREST CROSS STREET PARCEL I tMONALI <br /> CI i'!NA'.12 1 V l STATEZip CDD �✓ SI ?�hICNE s WITH AA CE <br /> CA !%�/ <br /> ✓ x Q CCAPORArCN Q 1NOIVIOVAL PAATNERSWP L�LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AG€NCY Q FEDERAL-AGENCY <br /> TO INDCATE -- <br /> OtSTIUCTS <br /> TYPE OF 3USINESS i I GAS STATION ' 2 OiSTn:$UTOR .0, IF INDIAN s OF TANKS AT SITE E.P,A. L 0-s raoumail <br /> RESERVATION <br /> Q 2 FARM Q a PROCESSOR Q 5 OTHEI 08 TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PW+ C =T14 ARCA(`^RC <br /> ll. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF AOCRESS INFORMATION <br /> VAIL'.NG OR STREET ADDRESS ✓ 'box Dmcm 71 INMCUAL Q LOCAL-4E,4cy ,� STATE-AGENCY <br /> IQ CORPCRATION Q PARTNERSHIP Q COUNTY.AGENCY Q F=ERAL-AGENCY <br /> CIN NAME STATE ZIP CODE I PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ DOA a NI cm © INDIVIDUAL CJ LOCAL-AGENCY Q STATE-AGENCY <br /> i Q CORPORATION Q PARTNER$HIP C1 COUNTY-AGO)CY Q FEDERAL-AGENCY <br /> CITY NAME I STATE I ZIP CODE PHONE s WITH AREA COOS <br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cali(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -1 • <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ tAu araieAy Q I SELF-INSURED 2 GUARANTEE lQ 7 INSURANCE Q A SURETY aOND <br /> Q S LMERCFCREOa Q 6 ExEUPnON Q 99 OTHER <br /> VT. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or 11 is checked. <br /> CHECK ONE BOX[NDICATING WHICH ABOVE ACORESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND B1LL:NG: I.= IL U III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL.CANTS NAME(PRINTED46StCNATURE) APPLICANFS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY a f+ <br /> LOCATION COCE -OPTIOL� CENSUS TRACT s -OPTIONAL SUPVISOR.DISTRICT GODS -P NAL <br /> 'Cl t/ 147 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-31) FCRG43iII/S' <br />