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STATE OF CAUFORN IA <br /> TE WATER RESOURCES CONTROL BOARD . W L-J,•••., -'t <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FOR"' A aC�yyjj�Wil; <br /> y <br /> COh1PLETE THIS FORM FOR EACH F,46LITYISITE <br /> MARK ONLY I_ 1 NEW PERMIT i'1 7 RENEWAL PERMIT $ CHANGE OF INFORMATION ri 7 PCRMA Y TE <br /> CNE ITEM i_I 2 '.NTERw PERMIT I_ 0 AMENDED PERMIT <br /> a icMPoRARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION & ADDRESS•(MUST BE COMPLETED) <br /> ------------- <br /> UdA,`,R.ACILITY NAME I j ,// I NAME OF OPE;ATOR <br /> oO W.. NEAREST CROSS STREET I PARCEL AICRTONAq <br /> D:ry.vA�.IE <br /> I STATE I ZIP OODE SITE PRONE s WITH ApEA CCOE <br /> Jx, lieL CA <br /> TO INOCATE CCRPOPAT:ON CT) INDIVIDUAL PARTNERSHP f LOCAL-AGENCY CI COUNTY AGENCY <br /> DISTRICTS C SizTE.zGc'NCY �l FEDERAL is PE OF 3USINESS IJj 1 Cas STATION 2 DISTAGUTOR J IF MCIAN a CF TANKS�.,1i <br /> i1 7 :ARM A Pq RESERVATION <br /> �' feWNVWI <br /> u � OC'c SSCR Q 5THER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERG'cY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE r WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA COOE NIGHTS: NAME(LAST,FIRST) <br /> Rur, c A y APc nTc <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NA:.IE <br /> CARE Of ADDRESS INFORMATION <br /> MaIL!!.G CR STREET AOCRESS v W.0 NNr <br /> INDIVIDUAL C LOCAL-AGENCY <br /> STATE AGENCY <br /> CIT/HANE C CORPORATION = PARTNERSHIP `,; COUNrYAGENCY F <br /> ETaLAG"cNCY <br /> STATE I ZIP COCE PHONE r WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER <br /> CARE OF ADDRESS INFORMATION <br /> .NAIL;NG CR STREET ApORESS ✓ " <br /> p INDIV I U LOCAL-AGENCY CJ STATE MG Y <br /> CITY NAME <br /> J CORPORATION Q PARTNERSHIP 0 COUKrYAGENCY Q FEDERAL-AGENCY <br /> STATE 21P CODE PHONEr WITHAAEACOOE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ Ou o.Iicrr LJ I SEIF-INSURED = 2 GUARANTEE <br /> f1 S LETTER OF CRECIT I—'. S EXEWMN L, $INSURANCE Q A SURETY BOND <br /> C] 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE--BOX WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLNG: <br /> L� II.� III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLCANTS NAME(PRWT'c0 8 SXiVANRE) APPLICANTS TITLE <br /> DATE MONTWOAY/YEAR <br /> LOCAL AGENCY USE ONLY I — Z <br /> COUNTY a <br /> ` JURISDICTION a FACILITY a <br /> LOCATION GOD -OP /ONAL CENSUS TRACT) •OPTIONAL <br /> 2 SUPVISOR•OLSTRK T CODE -GF I C AUL <br /> THIS FORM mUbI BE ACCOMPANIED BY AT LEAST(t)ORMORE PERMIT APPLICATION• FORM ZJ,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM z(SBI) <br />