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U) <br /> v STATEOFCAUFORNIA o <br /> STATE WATER RESOURCES CON a w p <br /> UNDERGROUND STORAGE TANK PERM o Z <br /> COMPLETE THIS FORM FOR EACI a i <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT U lfj' <br /> w <br /> ONE REM ❑ 2 INTERIM PERMIT U <br /> ❑ ! AMENDED PERMIT <br /> I. FACILITY/SITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) w <br /> SRA OR FAqIqTY NAN r <br /> NAME Q <br /> ZVLJ 2 <br /> ADDRESS NEAR : Q <br /> O ti <br /> fr UN <br /> CITY NA C) Z <br /> STA' � <br /> ( o <br /> V Box <br /> TO INDICATE 0 CORPORATION Q INDIVIDUAL PARTNERSHIP Q LOCAL- F- O <br /> DSTRII Z <br /> 'I owner al UST is A public ape ,00rrsu to tM WIovMp:nerne 01 Supervisor o/division,section,or an <br /> TYPE OF BUSINESSaf 1 GAS STATION ❑ 2 DISTRIBUTOR �' G <br /> 3 FARM Q 4 PROCESSOR O 5 OTHER U <br /> EMERGENCY CONTACT PERSON (PRIMARY) z U <br /> H <br /> DAYS: NAME(LAST,FIRST) PHONE A WITH AREA CODE C > <br /> _ TH _ 1 <br /> HONE a <br /> NIGHTS: NAME(LAS ,FIRST) PAREA E I w 110C0 <br /> F- <br /> o x <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED w1-4 <br /> NAME Z a W <br /> x <br /> MAILING OR STREET ADDRESS U <br /> I H iCY <br /> C1TV NAME <br /> I <br /> a <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) U <br /> NAME OF OWNER I� <br /> T7 <br /> a <br /> MAILINGOR STREETADDRESS U W <br /> W NCY <br /> w � .GENCY <br /> CITY NAME r <br /> V <br /> Z Z <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT I La m w CLO <br /> D <br /> TY(TK) HQ 4 4- -�❑ Z <br /> O U <br /> o p <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BI ~ <br /> ✓ yyb� (] 1 SELF-INSURED 2 IYLBONO <br /> O 5 LEREROFCREDIT W I U w <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal nc CL x J. <br /> w U <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOP UE( y ¢ U 'moi <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY Anu, ^' <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE IDAIc <br /> LOCAL AGENCY USE ONLY f4)(i Z <br /> COUNTY a JURISDICTION tl FACILITY t <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPT;GNAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE ImPo flOWONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3A73) FORp(DMRI <br /> Y r <br />