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� <br /> O <br /> STATE OF CALIFORNIASTATE WATER RESOURCES CONTROL BOARD �0 + <br /> U5NDERGROUND STORAGE TANK PERMIT APPLICATION- FORM AV/� p� <br /> I <br /> :o y` <br /> COMPLETE THIS FORM FOR EACH FACILtTYISITE <br /> =.\ <br /> MARK ONLY n NEW PERMIT ❑ <br /> ONE ITEM ] RENEWAL, PERMIT <br /> ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMAN <br /> f INTERIM PERMIT ❑ a AMENDEO PERMIT CLOS SITE i <br /> ❑ 8 TEMPORARY SITE CLOSURE .� �Jv/ <br /> I. FACILITY/SIT FORMATION&ADDRESS-(MUST BE COMPLETED) <br /> EACORESS <br /> R FACILITY NAME <br /> NAMECFOPERATOR <br /> � NEAREST CROSS STREETIAII PARCEL/ <br /> AME T-('j <br /> STATE ZIP CODE / SITE PHONE r WITH AREA CODE j <br /> ✓ Boz CA CfS�I' �?-,eTO INDICATE r_I CORPORATION INDIVIDUAL Q PARTNERSHIP Q LOCAL AGENCY <br /> DISTRICTS C:1 CAUMYAGENCY � STAT � Oy <br /> TYPE Of BUSINESS 1 OAS STATION � FEDEPALdGENCY <br /> PROCESSOR] FARM A <br /> 2 DISTRIBUTOR ✓ IF INDIAN r OF TANKS AT SITE E.P.A, I.D,r IbPTlmaq <br /> O 5 OTHER �OR TVRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> CAPS: N M �r,FIRgn EMERGENCY CONTACT PERSON (SECONDARY • <br /> D / PHONE s WITH AREA CODE ) optional <br /> S�—3 V7 GAYS: NAME(LAST,FIRS <br /> NIGHTS: NAME(LAST.; ST) ,V PHONE r WITH AREA CODE <br /> NI HTS: NAME(LA ,FIRST) <br /> IPROPERTY OWNER IN <br /> NAME FO MR ATION- MUST BE COMPLETED PH rQF <br /> /�� <br /> ^_Y ( CAPE OF ADDRESS INFORMgT10N <br /> .NAILING Oq STREET ADDRESS (/ Pr <br /> ✓ WbaLL 0 INDIVIDUAL <br /> CITY NAME D CORPORATION LOCAL-AGENCY [!I FEDERAGENCvC <br /> SRN/n� �p.N�T STA ZIP CODE PMTNEPSWP � COUNTY.IGENCV � FEDERAL-AGENCY <br /> ON PHONE r WITH AREA CODE <br /> III. TAN "FORMATION-(MUSTBECOMPLETED) <br /> NAMED F OWNER <br /> M i NG OR STREET ADORES- r /- <br /> v T✓ M)A10 �Q. -/ ✓ 00 Y101"' O INDIVIDUAL <br /> CI AME l • 'MOrY I CORPORATION LOCAL-AGENCY Q STATE AGENCY <br /> �] S7ATE DE PARTNERSHIP � COUNTY-AGENCY 0 FEDERAL AGENCY <br /> I ZIP CODE PHONE s WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST Z I ` U \ ✓,1 9 U —� jo c� , <br /> (TK) HQ <br /> 474 - <br /> TY Q 2 • II 916 323-9555 if questions arise. <br /> D <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ho:b'ubKyr 1 SELF-INSURED <br /> O S LMEROFCREDrr O t GUARANTEE <br /> 1!:5RANCE <br /> GU [� ] <br /> e EXEMPTION gq 07NER O A SURETY BOND <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent ID the lank owner unless box I Drfl ecked. <br /> CHECK ONE SOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIF)CATIONS AND BILLWG: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,/S ITa AND C RR(4z= <br /> APPLICANTS NAME(PR WTEO 8 SIGNATURE) <br /> APPLICANT'-TITLE <br /> DATE MONTWDAYiVEAR <br /> LOCAL AGENCY USE ONLY 3 30-9Z <br /> COUNTY# /' <br /> ® 69F-VI,,S® �URISOICTIONX <br /> FACILITY K <br /> LOCATION CODE (-OPTIONAL � I G TJ O D D CENSUS RA <br /> TCT s -OPTIONAA <br /> q yo ISUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS-91) MUST <br /> FORBE ACCOMPANIED BY <br /> M q(S91) AT LEAUST(1)OR MORE PERMIT APPLICATION• FORM 8,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. ' <br /> FORON,7A.5 <br />