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STATE OF CALIFORNIA <br /> Z-zz a-WE7-'C-A_ i2m,(.k 0 STATE WATER RESOURCES CONTROL BOARD C 2 1C, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATI",r.,f <br /> COMPLETE THIS FORM FOR EACH FACILrrY/SITE <br /> MARK ONLY Ev�' NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY C <br /> ONE ITEM El 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OWACILITY NAME NAME OF OPERATOR <br /> ADORES NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> BOX <br /> 1/17 <br /> TO INDICATE CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TYPE OF BUSINESS i".GAS STATION 2 DISTRIBUTOR DISTRICTS IF INDIAN #OF TANKS AT SITE I E.P.A. 1.D.#(optional) <br /> 3 FARM 4 PROCESSOR = 5 OTHER] OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)'vphvnu <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS �V�bo,,Pindca'o INDIVIDUAL LOCAL-AGENCY STATE-AGFNCY <br /> P,0 ,&�il Co ORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION (MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILINd OR STREET ADDRESS / box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 'Oeo'17� 5-&w 92,-CORPORATION PARTNERSHIP COUNTY-AGENCY 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) HO �� �� \- <br /> V. PETROLEUM UST FINANCIAL RE.SPONSIBILITY WYUST8ECOMPLETED)—IDENTIFY THE METHOD(S) USED <br />