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I <br /> STATEDFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL_BOARO <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COOkETE THIS FORM FOR EA UTYISrrE c •,""} <br /> MARK ONLY I NEW PERMIT RENEWAL PERMIT S 04ANM OF INMAMA71ON 7 PER ENTLY frE� <br /> ONE ITEM ! 2 INTERIM PERMIT I a AMENDED PC-RMIT g TS/PORAAY SITE CLOSURE <br /> I. FACILITY/SITE INFORMA71ON&ADDRESS•(MUST BE COMPLEI ED) <br /> C9AO A 1ITYNAME /� _ t( i NAW OFCPERATOR q <br /> aG RES i //4/I/' /C���J t/�--.', � NEARE' STR c: i PMC£1.e(OP►10NALi <br /> G ®O&I <br /> C:iY NAME "��� <br /> STATE <br /> ZIP^^CE ! SITE PH E s W1714 AREA CODE <br /> : z <br /> I CA <br /> �X 2J y S 2 Z <br /> To INMTE COR RATION tt�IVIOWL ?MTNERS4gp � I�=UM AGENCY -7 STATE-AGENCY, - FEDEr'.AL•AG'cNCY <br /> YPE OF 3USiNESS t GAS STATEN F7, 2 DISTRIBUTOR / :F imcm s OF 3AN ,AT SITE E.P.A. L 0.s(comm) <br /> `—� AESERVATICN <br /> j" 3 FAAM a PROCESSOR (� s OTHER CA T RLQ <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) P40NE s WITH AREA CODE JAYS:NAME HAST.=QRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE s WITH AREA CODE NCx4TS:NAME(LIST•CRSS) � <br /> a WrrW AROA CC i; <br /> IL PROPERTY OWNER INFORMATION• MU BE COMPLETED <br /> NAME i CARE CF ADDRESS INFORMATION <br /> !aA1L1N AsSTRE�.AC ESS /o j ✓ 7gls a e IN011110LIAL LOCAL-AG84CY STATE-AGENCY <br /> C..RPGRA7SQN PARrNEeiSFBP COUNTY-AG'eNCY ;MERAL44EENCY <br /> PHONE m WITH AREA <br /> III. TANK OWNER INFORMATION•(MUST BE COMPL_S i ED) <br /> NAME w CARE OF ACCAESS INFORMATION <br /> uAIL N A STREET ^KESS• .� ✓ m amu IN UAI LCL-AGENCY STATS-AGMCY <br /> O 'G �✓ ' _C RAT4pM a PARTNEeiSF9P _CCUNTY•AG'ENCY -tt0E;AL•AG'SNCY <br /> CITY NAM �j� �H s WITH AREA CCCE <br /> r // STAG I ' �/ fs l/ ILC <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Cad(916)323-9555 it questions arise. <br /> I Y(TK) HO <br /> V. PETROLEUM UST FlNANCJ ONSIBILJTY-(MUST BE COMPLE"i'=,.D)—IDENTIFY THE METHOD(S) USED <br /> ✓ eos a I sLFINSUR® _2 GUARANr1= ^3 INSURANCE 4 SURE-if MHO <br /> 5 Lr.7moFc;tmr —,6 SwAgmif 77 A oTNER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II 44ded. <br /> I <br /> ^:+ECIC ONE 3OX INC:.CATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIiCATICINS AND 8X.L!NG: L 1 IL I aL— <br /> MS FORM HAS SE:N COMP-'TED UNCER PSVAL i Y OF PERS URY,ANC TO 7-r:F 3-CST OF A fY XN09VLECGE;S i RUE ANC CORRECT <br /> i^+"_:CA.tTS NAME,-::.v rE D a SIGNATUAE: APPLICANTS TM..-E �^,ATe mCNTH f0AYfYEAA <br /> LOCAL AGENCY USE ONLY <br /> C-UNTY s i- 7yf' JUTICTICKs FAC.IITY <br /> ..;AT•C� PE ?'1CnI.AC Cc..Ji,S +AC'a .pp�g)��� S'.:Pf:SC:-C S•_IC-CCCE -.^•P:.CY=L <br /> �t <br /> THIS ECRM NAUST BE ACCOMPANIED BY AT LEAST(1)CR MCRE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE!NFCRMATICNa ONLY. <br /> FILE THIS FORM WITH THE LOCAL AGENCY SMPL EMENTING THE.UNCERGRCUNO STORAGE TANK REGULATIONS <br /> fir; <br />