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'�yo�-ces cJ <br /> v STATE OF CALIFORNIA Q ? <br /> STATE WATER RESOURCES CONTR 0 <br /> UNDERGROUND STORAGE TANK PERMIT I - FOYRA <br /> a � o <br /> • C�(II01N' <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY ❑ EW PERMIT 173 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENT Y CLOSED <br /> ONE ITEM u 2 INTERIM PERMIT ❑ 4 AM 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/Sl INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> + <br /> DBA OR FICIL17&AME �, l l o NAME OFERATOR <br /> L", <br /> ADOR NEARESTC S S REET PARCEL It(OPTIONAL) <br /> T <br /> 44 0!��dgek <br /> CITY AME STATE ZIPCO SITE PHONE#WmDE <br /> A CODE <br /> BOX (, CA S3 O - 3- Z <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ❑ 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION #OFF 3TAN AT SITE E.P.A. I.0.#(optional) <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#WITH AREA CODE DAYS: E(. FIRST) <br /> NIGHT11 <br /> S: N (LAST.FIR PHONE#WITH AREA COOE NIGHTS: N(ArAM LAST IRST) <br /> P NER INFORMATION•(MUSTJDE COMPLETED <br /> NAME _0 :11jRE OF ADDRESS INFORMATION <br /> � Lr <br /> MAILING ORSTREET ;ESS ✓ box io indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Kt Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE <br /> PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER (( CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADO SS• ✓ box Io indicate Q INDIVIDUAL Q LOCAL-AGENCY 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)323-9555 if questions arise. <br /> TY(TK) HQ 14 4 - �:7 /14-' <br /> 711117 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—ID IFY THE METHOD(S) USEDwl <br /> ✓ box to indicate Q 1SELF-INSURED Q 2 GUARANTEEQ 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION = 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank ow er unless bo I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.❑ 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGN<TR AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHlDAYNEAR <br /> LOCAL AGENCY USE ONLY (� <br /> COUNTY# JURISDICTION# FACILITY# <br /> Ll -L-LE :Aoo�� <br /> LOCATION CODE OPTI(;AIAL CENSUS TRA T# -OPTIONAL 1 SUPVI R-DI <br /> THIS FORM MUST BF ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM 8,UNLESS THIS IS A CHANGE OF SITE INFO NON Y. <br /> FORM A 112 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> `� FOR0033A-R6 <br />