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'p-50Un Cf4 <br /> O MAN& E <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD MAY 13 1993 3 - <br /> UNDERGROUND STORAGE TANK PERMIT APPLIg&T)ftTMft HEAD <br /> • ,.���,� <br /> COMPLETE THIS FORM FOR EACH FACILRY/SITE PERMIT/jERVIGO <br /> MARK ONLY � 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE Q , <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F CILITY NAME i 90 F O RATO - <br /> E ^ Q <br /> kl <br /> ADORES PARCEL o(OPTIONAL) <br /> I N EST CROSS ST ...J � <br /> CITY NAVE ^ / �• •� vZ STATE ZIP CODE SITE PHONE is WITH AREA CO <br /> � r- cA 3 -271 <br /> ✓ BOX TO INDICATE C CO RATION DIVIDUAL PARTNERSHIP 0LOCAL-AGENCY OCOUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR '/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(ptionai) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: N ME(LA FIRST)^ PHONE#WITH AREA CODE DAYS: NAM ST,F RST)( / n �! (]oO �n/�0 IF <br /> NAME( T,FIRST)J nn PHO TH AREA CODE <br /> NIG14T NAME(LAST,FIRST) /� vC�— , <br /> #G... I%`� -H .WITH G: <br /> II PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> ME I CARE OF ADORES INFO MA710N /—� - ` <br /> 1 a0 ' e(o� Cow, U=n v . �,- ff '``1 <br /> MAILI 11 STREET DDRESS O ✓ box to indicate h INDIVIDUAL LO L-AGEN STATE-AGENCY <br /> CORPORATION = PARTNERSHIP Q COUNTY-AGENCY U FEDERAL-AGENCY <br /> CITY NAME I STATE ZIP CODE PHONE#WITH AREA CODE <br /> �' q0a02 - C �' o - 3t -� <br /> I , TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> �Qdll OF OWNER n CARE OF ADDRE 5 INFOR I N <br /> MAILING OR STREET ADDRESS V <br /> ✓ box to ina"te INDIVIDUAL =1 LOCAL GENCY 0 STATE-AGENCY <br /> SS CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CO E <br /> 3 — o <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 7474 -I D 10 10 11 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate i SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> __j 5 LETTER OF CREDIT n 6 EXEMPTION 99 OTHER <br /> VI EGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> \C/CK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= II.= III <br /> ..X <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE // DATE MONTHI AYNEAR <br /> �' Yt� ON r ��- v . g S t-S�i <br /> LOCAL AGENC �Lj <br /> USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# Q.GO S g3S <br /> Q 3 � s bi <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 'SUPVISOR-DISTRICT CODE -� OPTIONAL —\� <br /> - 60 2 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF SITE I T N ONLY. <br /> FORM A(5-91) FOR0033A-5 <br /> I <br />