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STATE OF CALIFORNIA <br /> - STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA o <br /> -y COMPLETE THIS FORM FOR EACH FACILRYISITE `'�•aa�'' <br /> MARK ONLY VI 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ ] PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 8 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR _ <br /> WCi Yy.L L � L <br /> ADDRESS NEAREST CROSS STREETPARCEL A(OFrIONAIj <br /> 3S50 S (' LJ� t- (.o' 4LVA" <br /> CITY NAME1 _� STATE IP CODE SITE PHONE#WITH AREA CODE <br /> < -r�c�/Tw CA `(5"7- 15 9t( )L(i2 <br /> I/ PDX L3GCARPORATKIN I1 INDIVIDUAL O PARTNERSHIP LOCM-AGENCY ED COUNTY-AGENCY' STATE-AGENCY' =1 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> ' <br /> If inner of UST le a public agency,wnplOe the following:name of Supervisor of d'"ion,c Ion,or officewhich operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR = <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(eptimal) <br /> RESERVATION <br /> ❑ 3 FARM ❑ 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> . .ter -.__..x 'rl —SI1C L"✓MICE: - _75`11.._ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITHAREACODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Y , <br /> If. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Kc"A <br /> MAILING OR STREET ADDRESS ✓ box blMicale INDIVIDUAL D LOCAL-AGENCY O STATE AGENCY <br /> (7, 1? i j C'7 (.' O CORPORATION I[ePARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 111. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> (�•✓tl U <br /> I-S - i .1 <br /> MAILING OR STREET ADDFUS l ✓ box biMia INDIVIDUAL D LOCAL-AGENCY 0 STATE-AGENCY <br /> LF G' Y"v C ' C l✓G({ E14 CORPORATION 0 PARTNERSHIP COUNTY AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 41z <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 44- - o ) g a s k <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ My biMkate E-1 1 SELF INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BONO <br /> f= 5 LETTEROFCREDT O 6 EXEMPTION O 99 OTHER <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: 1.❑ II.❑ III. .� <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> CrOU�NTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) FOR9IXi3AHi7 <br />