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+ �_&�` � °� � a _ �,� ,.>•,�- ?'r„ ,;r wd� fir' � �* �- ,� �� �,.�.y+�''- � _ �y <br /> 44, <br /> STATE OF CALIFORNIA ^r• ° <br /> STATE WATER RESOURCES CONTROL BOARD <br /> p <br /> f` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 1 NEW PERMIT F—] 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT .`4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAMENAME OF OPERATOR <br /> old cs <br /> ADDRESS/ NEAREST CROSS STREET PARCEL It(OPTIONAL) <br /> r 7 d 0 � 19Q o o c- <br /> CITY NAME/_ STATE ZIP CODE SITE PHONE#WITH AREA CODED�r <br /> 7rt1C CA <br /> s <br /> ✓ Box <br /> TO INDICATE CORPORATION [ INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> { TYPE OF BUSINESS ✓ IF INDIAN J�� <br /> ANK ATSITE E.P.A. I.D.#(optional) <br /> 1 GAS STATION 2 DISTRIBUTORRESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHEROR TRUST LANDSf /C <br /> o. EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NA (LAST FIRST) / ��� <br /> ..3 8 /z </ c!'o T7cGr C5 J C� <br /> NIGHTS: NAME(LAST,-FIRST) PONE$WITH AREA CODE NIGHTS: NAME( ,FIRST) .rr <br /> r <br /> ► l3/- s/ ,S' , 3/ :ARS OD <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> 5 „;,: NAME CARE OF ADDRESS INFORMATION re <br /> 0a Ian <br /> 4, MAILING OR STREET ADDRESS ` ✓ box b indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> pmt o(�,,., CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> ' CITY NAME ”+ - STATE ZIP CODE PHONE#WITH AREA CODE <br /> k C." ( l-� S .� L.;2 0 <br /> 1. <br /> III. TANK OWNER tNP RMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER)` CARE OF ADDRESS INFORMATION <br /> MAILING OFt STREET DRESS ✓ box to indicate <br /><.`.. INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> -aozz <br /> t� CORPORATION (] PARTNERSHIP E:11 COUNTY <br /> [:] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 47 0Y) <br /> t .j�o2f <br /> IV.BARD OF E61LIA-LA610h-Rf STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555#questionspri <br /> TY(TK) HQ 4 4 - 010 <br /> I <br /> TK <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> i <br />`, ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT []6 EXEMPTION 99 OTHER <br /> I 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: <br /> HIS M HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> (;CAL <br /> A S AME PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> x it !" <br /> AGEVY USE ONLY <br /> x1 <br /> COUNTY# JURISDICTION# FACILITY# <br /> mF TTI <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL a SUPVISOR-DISTRICT CODE -OPTIONAL <br /> t) J�; r <br /> qtr° 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 /> FORMA(5 91) FOR0033A 5 <br />