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/► �7 OUR e <br /> 1/4 ATF OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD 3` <br /> p UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA ae o <br /> •C�IIfOR N,� <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT F—] 3 RENEWAL PERMIT IVS CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM a 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAM <br /> R <br /> ADDRESS I NEARES TREET PARCEL#(OPT <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> T DIC <br /> NTE CORPORATIONINDIVIDUAL =PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY Q FEDERAL-AGENCY <br /> " DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR <br /> %/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM = 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> CY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N (LAST,FI PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) rL U 4 1'7 0 2� <br /> Av SAI- .910 4 0&:2 L i IV AJ" PHONE a WITH ARPA(011F <br /> NIG S: NAME(LAST,FIRST) PHONE#WITSAREA CODE NIGHTS: NAME(LAST,FIRST) 11 <br /> PHONE#WITH AREA CODE I <br /> II. PROP OWNER INFORMATION- MUST BE PLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS j ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 3 U 3 2 !,1/ Gi_�f C-1 66 U =CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> <Q1_v z-- <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> i??Lc 5 c, <br /> MAILING OR STREET ADDRESS ✓box b Indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> t) `l „ =CORPORATION E:] PARTNERSHIP E::] COUNTY-AGENCY FEDERAL-AGENCY <br /> ,CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 15 W? �� s�a. C'-�' 1 9S35v� S/0-y17 ! <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - Q g y O <br /> V. PETROLEUM UST FINANCIA,01ESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE O 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 6 EXEMPTION 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 ch ked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= II. III. <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) P LICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 -7 , �_;I / 7 5 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST 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) FOR0033A-5 <br /> 0 4 4� <br />