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FlsO <br /> r pp 3 <br /> 4" <br /> STATE OF CALIFORNIA <br /> STA <br /> r E - TE WATER RESOURCES CONTROL BOARD 3 , <br /> ` UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH ACILITY/SITE <br /> MARK ONLY1 NEW PERMIT 3 RENEWAL PERMIT [0"5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM F-1 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) w:,.-�CU Fu C( t ] v <br /> DBA R FACILITY NtaME NAME F ERATOR <br /> a ll. « BOO (� �► <br /> ADDRESS NEAR ST CROSS STREET' PARCEL#(OPTIONAL) <br /> IV. <br /> ' CITYN STATE SI�,T�5PHONE#W H AREA COD <br /> ` CA '10 e>C c� <br /> ✓ BOX <br /> _ TO INDICATE ORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> D�TRICTS` <br /> e,. TYPE OF BUSINESS T GAS STATION 0 2 DISTRIBUTOR V' <br /> IF INDIAN #OF TAN S AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 5 OTHER` 0RTkST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: N ME(LAST ST) PHONE#WITH AREA CODE D YS: NAME(L ST,FIRST), <br /> z` N � oris_ - 8 o �fC1rc, evta�Ce (t8cv-�? — <br /> NIGHTSk NAME( T,FIRST) PHONE#WITH AREA CODE NIG S: NAME(LAST,FIRST) <br /> !n E'flaHCe (18nv a-63 11&3 aA2PHONE WITH AREA CODE <br /> - <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM CAR f $S INFORMATION <br /> itVo t <br /> 3 <br /> MAILING OR STREET ADDR SS ✓x tD indicate I <br /> �O�INNDIVIDUAL � LOCAL-AGENCY 0 STATE-AGENCY 4 z 6 <br /> rJ (� �7Me <br /> [ 'CORPORATION LF PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CI �N E S7�TE ZIP DE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETE <br /> NAM OF OW�N^E�RI y� CARE OF ADD ESS I FORMATION <br /> Cv C Q - �(f. �i�-f.�f�� '7� r ` �': .� lf�t p : <br /> MAI GORSTREETADORESS { 9, �✓ffboxtoindicate INDIVIDUAL LO AL-AGENCY ATE-AGENCY <br /> - J �J CORPORATION PARTNERSHIP OCOUNTY-AGENCY [] FEDERAL-AGENCY <br /> CITY NAME I 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 4 4 - (� C7 Q b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> F Fbox to indicate SELF-INSURED =12 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT D 6 EXEMPTION 99 OTHER <br /> m <br /> 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 /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> ro; t <br /> t r. <br /> APPLICANT'S NAME % C APPLICANTS TITLE DATE MONTH/DAY YEAR <br /> ff <br /> V. ss <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY <br /> ` LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL #� <br /> "4, <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) FOR0033A5 ' <br /> '�"�.°�, = �, v �- '•; �_ A l� • � +ave"" 'sw"'w r:. ."� E �s,>�-'t`"„ �'4 �� .. <br /> c. <br />