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x dal '8r yirw' V., <br /> ' STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F__j 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM a 2 INTERIM PERMIT 4 AMENDED PERMIT tD 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA 09 FACILITY NAME NAME OF OPERATOR <br /> ADORES NEAREST ROSS TREET PARCEL#(OPTIONAL) <br /> oad inco�n oad <br /> CITY NAME STATTEA 95207 <br /> 5 O 7 417E rNE j yl r nC(tJ� <br /> to <br /> V Box <br /> TO INDICATE CORPORATION 0 INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY 0 COUNTY-AGENCY' STATE-AGENCY' jr <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESERVATIONIF INDIAN <br /> x OF TANKS AT SITE E.P.A. I.D.x(optional) <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE X WITH AREA CODE DAYS: NAME(LAST,FIRST) HOE o Aq <br /> 474-4300 Emergency Control (455 - �7 <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIOHTS:NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> [AME CARE OF ADDRESS INFORMATION <br /> Desk Louana J Uribe <br /> AIL.fN1VQORSTREETADDR/E�SS 2646 Watt Avenue ✓boxiolnAoam M INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> .0. BOX 15t)38S33CORPORATION � PARTNERSHIP [�COUNTY-AGENCY I� FEDERAL-AGENCY <br /> CITY NAME <br /> STATE ZIP CODE P ITH <br /> CA 956-51 , <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER _ CARE OF ADDRESS INFORMATION <br /> same as above II <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION Q PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> box b Indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CRELIIT 6 EXEMPTION (] 99 OTHER <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 /> FcHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. IL III. <br /> a c <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTYCF PERJURY,AND TO T1415 8EST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 8 SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY Record I.D. <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS'TRACT0 -OPTIONAL 3UPVISOR-DISTRICT CODE -OPTIONAL <br /> 23.F <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) FOR0033AaI7 <br /> + <br />