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' STATE OF CALIFORNIA Ar r cO <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> - C�I,fOR H.r <br /> MARK ONLY 521 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED. ITE <br /> ONE ITEM EJ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ` \ <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME,OFJOPERATOR <br />'j ADDRESS ,rte NEAREST CROSS STREET FPARCEL#(OPTIONAL) <br /> Co ')z? CLU IZ4 Yep fS St-0'u cue, <br /> CITY NAMESTATEZIP CODE SITE PHONE#WITH AREA CODE <br /> '� CA <br /> �Z cK19S_zW 174,q —�D�J <br /> ✓BOX Q CORPORATION E INDIVIDUAL D PARTNERSHIP 0 LOCAL-AGENCY D COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'It owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS ED"_i GAS STATION 2 DISTRIBUTOR Q ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAS�j'R'ST) PHONE#WITH AREA CODE D YS: NAME(LAST,FIRST) Z� PHONE#WITH AREA CODE <br /> L ELL 4-"1 _ _ ec L /Sr�f <br /> Zs* <br /> NAME(LAST,FIRST) PHQNE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) P NE#WITH AREA ODE <br /> c r /L ( 2 �—LCJL-( '�s�8, ^ ,,��,t.. 0 5 2 <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boxto indicate [INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> (� Q CORPORATION 0 PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> 1,44 TL. ��'"..C <br /> MAILING OR STREET ADDRESS w ✓ box to indicate [� IVMUAL [� LOCAL-AGENCY Q STATE-AGENCY <br /> (p <br /> S 6,Gc l� (�1(#./ i�CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME �, l STATE ZIP CODE PHONE#Wei• ABEprA.CODE'l <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -m-- --r-7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate '0 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE F-1 4 SURETY BOND Q 5 LETTER OF CREDIT =6 EXEMPTION O 7 STATE FUND <br /> D 8 STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM = 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= 11.[::] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTF SIGNATUF'�Ei) TANK OWNER'S TITLE DATE MONTHIDAYYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m Cm a??I r s 1611 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# •OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL.. <br /> THIS FORM MUST BE ACCOMPANIED BY A ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ON, <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FORTH THE LOCAL AGENCY IMPLEMENTING THE UNDERG*STORAGE TANK REGULATIONS <br />