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PIP- <br /> 166�v�.r-s C <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 /> 1-1 <br /> MARK ONLY F__j 1 NEW PERMIT F__j 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DB 1` ILITY ME NAME OF OPERATOR <br /> ADDRESS`1 11 ( , 1 E REST CROSS STREET PARCEL N(OPTIONAL)L-11 <br /> CITY NAME STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> k o0� GIS # SAN � CA S h9 o c)I/ BOX <br /> l� S� <br /> TOINDICATE O CORPORATIONINDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY' FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of UST is a public age Y,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTORQ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) ��. S 1_4 <br /> PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS• AME(LAST,FIRS PHONE#WITH AREA CODIN NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> t— — <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> — / NAME S + CARE OF ADDRESS INFORMATION <br /> 1 <br /> MAILING OR STREET ADDRESS c ✓ box to indicate INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> Q O V 0 f, LAM V 0 CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME 6?1 ^ ST,14TE ZIP COME,1 -3 f t NE,M WITH IAEA CODE ` <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) V/� �!D_ cVyV/� <br /> NAME OF 9WNERCARE OF ADDRESS INFORMATION <br /> MAILING=STRET ADDRESS VS <br /> J ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY <br /> _?o to # \J CORPORATION 0 PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME ^O � STATE ZIP D� �{(� WITH AR A COD-7 <br /> f L1(4 <br /> IV.BOARD OF t1(EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. c7 <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE Q 4 SURETY BON <br /> O 5 LETTER OF CREDIT Q 6 EXEMPTION =99 OTHER K <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unles or is c ecked: <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 /> DATE MONTHIDAYYEOWNER'S NAME(PRINTED ERT AR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#f Q OD 5LID � <br /> FM 1011311191 [ it <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OP77ONAL <br /> 17-7 Za <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 REGULATIM <br /> FORM A(3193) FOR13A.R7 <br /> ��� ��jq <br />