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`� STATE OF CALIFORNIA ` <br /> 0 <br /> STATE WATER RESOURCES CONTROL BOARD W�,n�! 8 <br /> C UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA ,,, <br /> COMPLETE THIS FORM FOR EAC CILRYISITE <br /> MARK ONLY ❑ I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAO F IU NAME //y� NAMEOFOPERATOR <br /> Inir, -- � <br /> ADE S NEAREST CROSS STREET PMCEL/IOPf10NAy <br /> n / <br /> LITVN STAC21P���� SITE PHONE&WITH AREA CODE <br /> ABOX <br /> C� <br /> TO INDICATE O CORPORATION D INDIVIDUAL Q PARTNERSHIP DIS�CTSEND a COUNTY-AGENCY STATE AGENCY O FEDERAL-AGENCY <br /> TYPE OF BUSINESS ❑ I GAS STATION ❑ 2 DISTRIBUTOR O RESERVATION A OF TANKIi AT SITE E.P.A. L D.#(opfbnaq <br /> Q 7 FARM a A PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE•WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> nps <br /> Il. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ EPxbNAIeaM INDIVIDUAL Q LOCAL-AGENCY O STATE-AGENCY <br /> =CORPORATION PARTNERSHIP O COUNTY-AGENCY Q FEDERAL AGENCY <br /> CITY NAME STATE ZIP COOS PHONE A WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓box Nwtm INDIVIDUAL a LOCAL-AGENCY O SIATE-AGENCY <br /> O CORPORATION O PARTNERSHIP Q COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK),HQ 4 4 Q ?-I q <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ oNA it I SELF-INSURED O 2 GUARANTEE O I INSURANCE O A SURETY SONO <br /> Cl 5 LETTEROFCREOIT O&EXEMPnON w OTHER <br /> 71 <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.❑ II.❑ IN.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# Co,7K.�tE JURISDICTION# FACILITY# <br /> 32T (111/17 /� <br /> LOCATION CODE -77L CENSUSTRACT# - TIONAL SUFV180R-DISTRICT CODE -OPTIONAL <br /> Z 3 Z <br /> THIS FORM MUST BE ACCOMPANIES BY AT LEAST(1)OR MORE PERMIT APPLICATION• FOR B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. /) <br /> FORMA(5-91) <br /> 1 FORWSIA3 V <br />