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,AW f <br /> STATEOFCAUFORNA <br /> STATE WATER RESOURCES CONTROL BOARD ! [1 T syr .o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORMiA' <br /> COMPLETE THIS FORM FOR EACH FACILrTY/SRE ,yF..,,,4 O •- �•",�,,,•' <br /> FMARK ONLY ❑ NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ a TEMPoRAgY $ITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NE NAME OF OPE TOR <br /> ADDRESS <br /> RCo 'V'VO,C, *2.1 �o k es QM�1TVS w1 441 NEAREST CRO55 STREET PApCELa(OPTpNAU <br /> UJ . VBG L"t0\tV <br /> CITY NAME cggE SITE PHONE*WITH AREA CODE <br /> ck!` <br /> Sr tJ STATE CA LIP <br /> v BOX <br /> TOINDICATE Q CORPORATION XINDNIDUAL O PARTNERSHIP Q LOCAL-AGENCY Q COUNTYAGENCV• <br /> DISTRICTS- Q srATE.AGENCY• Q FEDEIMUAGENCY' <br /> If ovnw al UST is a pudic agency,WWIMa the IOAowbg:narne of Supervisor d dimon,section,or office Mich operates the UST <br /> TYPE OF BUSINESS I GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN N OF TANKS AT SITE E.P. I.D.a foo(imag <br /> O 3 FARM Q A PROCESSOR 5 OTHER O RESERVATION A <br /> A <br /> O OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE*WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Atm E! g Ruse ROGezts F n►vl Rose J . 'Zi OG eRs <br /> MAILING OR VIS STREET ADDRESS ✓EosbiMlcala Q INDIVIDUAL Q LOCAL-AGENCY Q STATE AGENCY <br /> 1S�—� L\TV C0\r11 $'C_ Q CORPORATION PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> CITU NAME STATE ZIP ODEP NE* ITH AREA CODE <br /> ' T) uo 3Q)N COL �S 2 0l� �ioq <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWN%Q CW M r Il/M r, - CARE OF ADDRE`S`S INFORMATION <br /> r�,`M,I-CARO- I: R O S <br /> MAILING OR STRF�T.tDRESS Q ✓ Doi biMicau Q INDIVIDUAL Q LOCAL AGENCY O STArE-AGENCY <br /> 'O 3 O CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAMErA STATE ZIP CODE PHONE WITH AREA CODE I <br /> RRTCSL nolo -IDo3� (-II 1IS -Sgo4 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 1414- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓bis 10 rd N I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE <br /> D 5 LETTEROFCREDRO A SURE YBOND <br /> Q S EXEMPTION Q %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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ 11.❑ IIi,� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAM RINTED B SIGNED) OWQNER'S TITLE <br /> A� DATE pM}�p�TR`\R-OAYHEAR <br /> LN'�• W/ "LWT L� l�S <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N RISDICTION 0 FACILITY It <br /> � a <br /> LOCATION CODE -CWT/ONAL CENSUS TRACT* -OP77ONAl 9UPVSOR-DISTRICT DUDE -OPTIONAL <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 M113) OWNER MUST FILE THIS FORM Wrr"THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND" SAGE TANK REGULATIONS <br /> IRTITa001aM <br />