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STATE OF CALIFORNIA <br /> INTE'NATER RESOURCES CONTROL 90AR033 <br /> A <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOR1.4 A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> !MARK ONLY )I EN PERMIT '-1 9 RENEWAL PERMIT S CHANGE CF tNFCRMaTICN 7 PERMA Y LOSE? Sf7E 'j <br /> CNE ITEM 2 INTERIM PERMIT __ ♦ AMENDED PEALAIT I 8 ,cMPOAARY SITE CLOSURE O 2 <br /> I. FACILITYiS - ORMATION&ADDRESS-(MUST BE COMPLET ED) <br /> 33A OR FACILITY NAME NAME OF OPERATOR <br /> r-N Lel N ISe v-v I <br /> ACCRESS 114 L6— NEARESTCRCSSS7 EaT I PARCEL (OPTIONAL) <br /> STATE I ZIP COLE 6''24 6 S�;I+CNE A C/9 <br /> /9A- /' a 6 <br /> ✓ �x <br /> ' CCPCRarcN ARTE'SIP LOCAL-AGENCY couT •aGEAMl•AOINOICATE GENCY <br /> CSTRICTS <br /> ype OF 3USIN S 1 GAS STATION 1.� 2 OISTRi$t)TC1d ✓ IF INDIAN s CF TANKS AT SITE- -.P.A. LO s/ <br /> RESERVATION. - <br /> 7 FARM I_ a P90CESSCR OTi+ OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> C YS:NAME(LAST.FIRST) PHONE s WITH AREA COCE 0Aj:NAME(LAST.FIRST) <br /> NAME(LAST.-FIRST) PHONE s WITH AREA CODE TS:NAME(LAST IRST) <br /> ouryc:rmu Aac r^re <br /> II. PRLPERLY-2LNER INFORMATION• MUST BE COM 0) <br /> NAME CARE --10CRESS INFORMATION <br /> MA;L:?.G OR STREET AOCRESS ✓ o p INDMCUAL I1 LOCAL-AGENCY p 3TA�c-,C <br /> CORPORATION PARTNEASNP p COUNTY,IGENCYp --_EAAL4GEN:Y <br /> C;TY NAME I STATE ( ZIP COCE I PHONE s WITH AREA CCCE <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> `TAME OF OWNER CARE OF ACORESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ xs n norils <br /> tNonnouu p LCCAL•AGENCY (_(STATE AGENCY <br /> p CORPCRATION p PARTNERW Cj COUNIY•AGENCY p FMERALAGENCY <br /> CITY NAME I STATE 11 I ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOAR "OF EQUALIZATION UST STORA FEE COUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK} D FT-147,-101 <br /> V. PETRO UM UST FINANCIAL RESPONSIBILITY." MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ ».ales,. 1 SELF4"REO =2 GUARANTEE p] p♦SURETY MNO <br /> i�S ETTERC>OAEOTf C'8 ExEMPmN OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or h is checked. <br /> CHECK ONE 30X WDICATING WHICH A8CVE ADDRESS SHOULD 3E USED FOR LEGAL NOTIFICATIONS AND RILLNG, L= IL= IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPL.CANrs NAME(PRINTED&SIGNATURE) APDL CANrS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY �,✓ <br /> COUNTY x JURISOICT!ON x FACILITY X <br /> -­.. . . m 7] MVN -Z � = 10101Z%M� <br /> LOCATION CODE -7TIONAL ICENSUS T CTs-OPTVNAL SUPVISOR•DISTRICT CODE-OPTIONAL <br /> tol <br /> THIS FORM HUS//T BE ACCOMPANIED BY A!!T LEAST((i))OR,,�,MORE PERMIT APPUCAT1oN• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM.1(5.91) FCAOt133A-5 <br />