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STATE OF CALIFDF+NIAol, <br /> SON RESCURCES CONTROL SOARl7 <br /> UNDERGROUND <br /> ATNDERGROUND STORAGE TANK PERMIT APPLICATION - FORL1. <br /> t A �Z . <br /> CONIP+ETE THIS FORM FCR EACH FAC.L7Y,STTE <br /> HARK^,NLY �: I .NEW PERMIT i 7 RENEWAL PEnMIT I 5 CHANGE OF ;NFCRMATICN rp', 7 PSnMANENTLY C a <br /> C`!E ITE.'il 2 NTE.RIM ?ERMIT � s AMENCED ?EaM[T I 3 —,ELIGORARY SITE CLDSL;RE <br /> I. FACILITY SITE INFORMATION & ADDRESS-(MUST BE COMPLETED) <br /> CaA–A AC.0 Y NAM t /i �w � .NAME OF OPE;A TOR <br /> aCG ESS (/'(J NEARESTCRCSS STRE= I ?�CcL+;CPTgNAIy <br /> C;;Y if ; STATE + ZIP COC �/� ,r i SI1��+c s wl ARP CE <br /> I CA Ik rl <br /> ✓ iCz <br /> 77'OINrtCaTE _ J COUNTY-aCc1CY STAE.AGZ4CY FE0ERAL.AGeNCY <br /> L:RPCPA'DN NOIVICUAL P►HTE;Si,& LOCAL-AGE4CY <br /> OtSTFIC'S <br /> YRE CF 3L:SINESS t GAS STATION ice'; 2 DIST;;3UTDR ✓ .F�NDIaN a IF TANKS AT SITE E.P.A, L 0.a{aqumal? <br /> RESE�VATICN <br /> ] FARM a PRCCZ33CR 77 S 07FEA CR'AuSTLAND S <br /> ENIERGEyCY C^NTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> CAYS: NAME;LAST,FIRST) PHONE s WITH AREA COCE DAYS: NAME(LAST.FIRST) <br /> 0 <br /> N GHTS: .NAME;LAST,FIRS ) PHONE+NITH AREA COGS NIGHTS: "+AME IL.LST,FIRST) <br /> aur e:'AAT14 sacs r•^re <br /> Il. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> .4AmE CARE D-ADORE SS INFO RMATICN <br /> 4AA;L!.`.G Oa STAE.ET ADOF•ESS ✓ S0i nm*CWA (_ INCIYIOUaL LOCALiGE4CY !^ STAT-AUNCY <br /> CCRK;;ATICN = PARTNE.~•SAP COUNTY-AGEYCY ' ;=�S AI.4GENCY <br /> C;-,Y NA•sE tl STA—.c c ! ZIP COCE P�4CNE=WITH AREA=CE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> ,IasaE CF OWNER CARE OF ACOAESS INFORMATION <br /> uAIL;NG CR STREETADORESS ✓ ma 33mKae !NCmCUAL t-i LCCAL•ACbCY LJ STATE-95MY <br /> Q CCFtPCRATION Q PARTNERS-W C3UWy-AG[11CY FIMErA41kGENCY <br /> CITY NAME ! <br /> STATE I ZIP CODE i PHONE i WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call 41(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> 1 busnnaesr �; I SELF-INSUREO 2 GUARANTEE 7.NSURANCS = •SURE,f;ONO <br /> n 3 LETTER CF CAEOtT a DE MWITION © 90 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or 3's checked. <br /> CHECK ONE 3OX WCICATING WHICH A8CVE ACORESS SHOULD 3E USED FOR LEGAL NOTIFICATIONS ANO SrLLNG: L k I1L <br /> T!-1JS FORM HAS 43EEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY.KNOWLEDGE,IS TRUE AND CORRECT <br /> ADPL.CANT'S NAME[PFINITcD&SIG.NATLiRE) APPLICANT'S TITLE OATE MCNTWDAY/YEAA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISOICT!CN x FAC.LITY <br /> '7- OZ <br /> LOCATION C=1E •OPTIO L CENSUS T RACT s .GPI)ONAL SUPWISOR,DISTRICT CODE •P7 O,� A (� <br /> 7-5 60 <br /> THIS FORM ALIST 3E ACC"h1PANIED BY AT LEAST(111)OR MORE PERMIT APPLICATION- FORM 8, UNLESS THIS IS A CHANGE CF SITE INFORMATION ONL' <br /> ;ORM A I5-3 11 FOR, <br />