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STATE OF CAUFORMA <br /> `�a• <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMAC'2 <br /> COMPLETE THIS FORM FOR EACH FAC <br /> MARK ONLY 1 NEW PERMIT U 3 RENEWAL PERMIT 5 CHANGE 0= INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM !i 2 INTERIM PERMIT El 4 AMENDED PERMR D 6 TEMPORARY SITE CLOSURE Z <br /> 1. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME /t NAME OF OPERATOR <br /> lokeoq n <br /> ADDRESS I NEAREST CROSS STREET I PARCEL It(OPTIONAL) <br /> CRY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> S 4n C/c A., l - CA 9 5-,2 v--5-- 2 9 - Y3-/ k r <br /> I/ Box <br /> TOINDICA E Q CORPORATION Q INDIVIDUAL Q PARTNERBIOP [_LOCAL-AGENCYQ I COUNTY-AGENcy Q STATE-AGENCY FEDERAL-AGEN--Y <br /> DISTRI TS <br /> TYPE OF BUSINESS Q 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN s OF TANKS AT SITE E.P.A. L D.s(apl a ml) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR 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 /> /C I K -�1 Z09 - 5"y3— / 'A rnmr <br /> NIGHTS:NAME(UST. 1) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONr s WrrH AR=A CC)r)c <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME 1 CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ WX IDMCM <br /> Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> B I Q CDRPDRATIoN Q PARTNERSNIP Q COUNTY-AGENCY Q FED-cRAI•AGEICY <br /> CITY NAME STATEI ZIP CODE PHONE s WITH AREA CODE <br /> S io c k {z..., I Com/ C/s-z O�' I V S - �!y ze <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS 1 ✓ bOl bMDCAW Ql INDNOUAL Q LOCAL-AGENCY J STATE-AGENCY <br /> =CORPORATION i PARTNERSHIP Qi COUNTY-AGENc_Y Q FEDERAL•AGEOCY <br /> CITY NAME I STATE i ZIP CODE i PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(918)323-9555 8 questions arise. <br /> TY(TK) HQ '4 4 -1 p a (e <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ Oox b II1d1CAK r--1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCBO <br /> E SURETY ND <br /> Q'5 LETTER OF CRc_DrT QI 6 EXEMPTION Q!%OTHER <br /> Vl. LEGAL NOTIFICATION AND BILLING ADDRESS Lecal notification and billing will be sent to the tank owner unless box 1 or 11 is check <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. v. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED d SIGNATURE) APPLICANT'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION s FACILITY I; PF,V7-,4 /S <br /> LOCATION CODE -OPTIONAL (CENSUS TRACT* -OPTIONAL SUPVISOR.DISTRICT CODE .OPTIONAL <br /> D 3n Co 3a , it/<�_-�5 , <br /> THIS FORM 161UST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM.A(5-91) FOROM3A.5 <br /> 1 <br />