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iebO"" ee <br /> �` Wtl4 <br /> STATE OF CALIFORNIA D Aye a <br /> STATE WATER RESOURCES CONTROL BOARD ; <br /> UNDERGROUND STORAGE TANK PERMIT APPLICAT - RM <br /> Y," <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE JUN �4LtpoRj�'' <br /> MARK ONLY F__j f NEW PERMIT 0 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION � PE <br /> 7 R NENTLY CLOSED SITE <br /> ONE REM Ej 2 INTERIM PERMIT 0 4 AMENDED PERMIT � B TEMPORARY SA?lI1 fi�ftM <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) /SERVICE<S <br /> DBA OR FACILITY NAM NAME OF OPERATOR <br /> k d-N F60D 4- FU_EL KEiTa4 <br /> ADD ESS NEAREST CROSS STREET PARCEL 0(OPTIONAu <br /> 425 -MqGY _C LVc <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Rt9cy CAI q5 a 7--G 209 83-5_/665 <br /> T 10 Nq x (CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> M 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 t GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.#lcotlonal) <br /> ESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 4 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 15 <br /> JT <br /> 209 83b ///G rkJI9N I: 2.617 836 -241 Y&O <br /> NIGHTS�LJEE(LAST FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAC FIRST) PHONE 8WITH AREA CODE <br /> 1511. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> C. <br /> MAILING ORSTREET ADDRESS C• ✓box 10 Irdkate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> /- • 13 N60300 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> t C L - 3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNS CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -1010r5 (r <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box lo indicate +- t SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 5 EXEMPTION Q 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: L[::] II.X III.ED <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY f <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL Sl1PVISOIl-DISTRICT CODE -CIPTIONAL 12 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLicnoN- FORM B,UNLESS THIS IS A CHANGE OF SITE WORMATION ONLY. <br /> FORM A ON) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNSTORAGE TANK REGULATIONS RAIX419A417 <br />