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STATE OF CALIFORNIA <br />'ATE 'NATER RESOURCES CONTROL 80ARO <br />�j UNDERGROUNU`•9TORAG- TANK PERMIT APPLICATION FOR' A <br />C/ <br />MARK ONLY i I W PERMIT 1 O RENEWAL PERMIT F-- <br />CNE ITEM — 5 CHANGE OF INFORMATION 'i^ 7 PERMANENTLY <br />2 .NTERtM PERMIT A AMENCEO PERMIT 1 a TEMPORARY SITE CLOSURE <br />I. FACILITYISITE INFORMATION S ADDRESS • (MUST BE COMPLETED) <br />C3A U R FALILI TY NAME - <br />J lex . . , - <br />TOINOCATE -^ CORPORArON INOWIDUAL PARTNERSHIP <_ <br />E OF 3USINESS I GAS STATION L✓ 2 OISTR18UTOR <br />:_7 O FARM r—' A PROCESSCR = 5 OTHER <br />EMERGENCY CONTACT PERSON (PRIMARYI <br />DAYS: <br />A <br />01 - <br />STATEI ZIP COCE I SITE PI,CNE A WITH AREA CCOE <br />CA Gj�/ <br />ALAGENCY Q COUNTY.AGENCY. C STATE AGENCY �l FEDERAL AGENCYi�ACENC�YY FEDERAL AGENCY <br />J IF INDIAN ACFi vKS AT SITE E.P.A. LO. AAT SITE E. P. A. L0 -A <br />10a1p'L) <br />RiSERVATICN <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />DAYS: NAME (UST. FIRSTI <br />II. PROPERTY OWNER INFORMATION • MUST BE COMPLETED) <br />NAME CARE OF ADDRESS INFORMATION <br />MAl.:NC OR STREET ADDRESS J Em N Vwcau <br />CI INDNxwAL (_ LOCuAGENCY I= siarFAGENDY <br />n CORPCRATION �i PARTNERSMP COUNTYAGE.NCY C FYCERrvSL-AGENCY <br />Cl TY .NAME STATE I ZIP COCE I PHONE WITH AREA CODE <br />innn vv 14 Gn I PerU TINIA I IUrv•( IVIUb I t7IC <br />NAME OF OWNER <br />^"•'•""°"' L -i INDIVIDUAL LJ LOCAL -AGENCY Cj STATE -AGENCY <br />CORPORATION Q PARTNERSHIP (1 COUNrY.AGE.NCY Q FEDER.LLAGENLY <br />C N NAME I STATE I ZIP CODE PHONE A WITH AREA CODE <br />N Dn Aen ne <br />-- --- - - -- ..� r�� nwutrly I IvuNle[r • 1,au wt)) 3Z3-9000 II questions arise. <br />TY (TK) HO F4_1 4 -� <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY • (MUST SE COMPLETED) —IDENTIFY THE MMOD(S)"D <br />J Ou nrotAM L-1_. I SELHNSURED L_; 2 GUARANTE'e <br />l-: ] IMSURANC' Q A Suirfrl 20N0 <br />11 5 LETTEACFCREDIT C a EXEMPTION (] "OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing well be sent to the tank owner unless box I or 11 is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING_- L O IL [:] 114 <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF AIY KNOWLEDGE. IS TRUE AND CORRECT <br />PPL,CANrS NAME (PRINTED A SIGNATURE) APPLICANTS TITLE DATE MCNTHGAYIYEAA <br />v <br />COUNTY a JURISDICTION x FACILITY s <br />LOCATION COjtE . OPTIONAL CENSUS TRACTy,� TACNAL SUPVISOR-04STRICT CODE -CP7IONAL <br />THIS ECRM MUST BE ACCCMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION • FORM B, UNLESS THIS IS A CHANGE OF SrTF IMFnMUATInM (TMI V <br />PnRM A �ce�� <br />1 / FOR=A-S <br />