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*Ou.SES O <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD W dam, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION -FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED,SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O` <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) Q 'IID <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> T .4 ezo SZoP GYt p�_-SI T S. c�0-rc-N `D <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> ge+-- -r'2Ac y c,vD z c z - Z avt� — 0 4 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> T 2t"GY CA R 3 -+to NO NE <br /> ✓ BOX Q CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY' STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> It owner of UST is a public age complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTORREV IF <br /> INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) Q <br /> Q 3 FARM Q 4 PROCESSOR 0 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: NAME(LAST,FIRST) PHONE#WITH AREA CODE C .F <br /> Jv7c G.S. Si o- 5"�- - 86 0.0 C,j'. /Pt5beAE 9 -83 to- 742-2- x�V <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIR T) PHONE#WITH AREA CODE <br /> �U Tc.s G.3-. Sta-t89- - 1+ 5_�- JU TLA G S, DE 6RA I 5'I 0 <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> IAj 0 CORPORATION a PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> ' CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> cAc 9S 3 6 AbT A/-t I L*e>t_ E <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> GKAe- ZTIT JUTLN- <br /> MAILING OR STREET ADDRESS, N- <br /> V to indicate INDIVIDUAL l�LOCAL-AGENCY i� STATE-AGENCY <br /> Sg WEJ—( D CORPORATION O PARTNERSHIP COUNTY-AGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> P->4� C - <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> M44- - 0 13 $ IS 10 1-14 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 1 SELF-INSURED =2 GUARANTEE O 3 INSURANCE =4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION 7 STATE FUND <br /> 8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND b CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICjIONS AND BILLING: 1.0 II.❑ III. <br /> THIS FORM HAS BEEN PLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED& IGN RK OWNER'S TITLE DATE MONTHfDAYNEAR <br /> TANN, p�7 � ­tz <br /> LOCAL AGENCY US eG 7 <br /> COUNTY# JURISDICTION# FA <br /> EE � 1 <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 /> FORMA(6-95) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS 91-7(01 <br /> ��o/qf `(1-1 �� <br />