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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FOR%! A y` � <br /> COMPLETE THIS FORM FO ACH CILpfY(SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 C GE OF INFORMATION 7 PE AN NE TLY CY�.IOSEO ITE <br /> CNE ITEM n 2 INTERIM PERMIT C A AMENDED PERMIT TEMPORARY SITE CLOSURE �dn"7 <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> OBA OR FACILITY N ( , NAME OF OPERATOR <br /> AM <br /> C� ¢ 5 R A IT ZPrGIL <br /> ADDRESS T./ 69A-IV ;IQ NEAREST STREET PARCEL.(OPTIONAL) <br /> CITY NAME r 'v ( STATE 7Z'IIPPPCCCJODE SITE?N'a WITH AR=A�O�� <br /> ✓ eoz 3 Z <br /> TO INDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR Q RESEF INDDIAN a OF TAN T SITE E.P.A. I.D.s(oprimap <br /> 'Q 3 FARM Q 0 PROCESSOR S 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 /> _rohe Tlz !0/ 1 57A^_KA0__ <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> u c•WTH AREA <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME _T_0/� f±a � I CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ./ rorl NinOwax Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME I STATE I ZIP CODE _/ PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETE16) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ IWAMM4a10 Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY AGENCY Q FEDERAL AGENCY <br /> CITY NAME I STATE I ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4747, o b <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ [a,ck4iax Q I SELF-INSURED Q 2 UARANTEE Q 3 INSURANCE Q z SUAE7 <br /> 'e0N0 <br /> Q 5 LETrEROFCREDIT C3211 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I hecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. II.tDI IIL <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO RECT <br /> APPLCANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY q� <br /> COUNTY K S�,(� 2 JURISDICTIO x FACILITY l 5Ps s b <br /> o ' <br /> LOCATION CODE -OPTIONAL CENSUS TRACT S-OPTN3NAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(T)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(5-91) <br /> fCA0033A.5 <br />