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�t <br /> STATE OF CALIFORNIA o <br /> STATE WATER RESOURCES CONTROL BOARD W meg' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT L"�^ CHANGE OF INFORMATION 0 7 PERMANENT SED S E <br /> ,o E ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT S TEMPORARY S1T7 CLOSURE <br /> j/l. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> [ADORE <br /> BA OR FACILITY NAME ) NAME OF OPERATOR <br /> S r NEAREST CROSS STREET PARCEL N(OPTIONAL) <br /> J <br /> CITY NAME (�Lc/ STATE ZIP CODE SITE PHONE F WITH AREA CODE <br /> CA <br /> ✓ BOXLOCAL-AGENCY COUNTY-AGENCY' D STATE•AGENCY' 0 FEDERAL-AGENCY' <br /> TO INDICATE CORPORATION 0 INDIY46UAL PARTNERSHIP DISTRICTS' <br /> H owner of UST Is a public agency.complete the lollowing:name 01 Supervisor of division,section,or oflioe which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR O ,/ !F INDIAN 4 O TANKS AT SITE E.P.A. L D.x(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 0 WITH AREA CODE DAYS: NAME(LAST,FIRST] PHONE#WITH AREA CODE <br /> /C7�11*i1 i'•i <br /> NIGHTS; NAM (L T,FIR TI PHONE S WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE <br /> �y PHONE 0 WITH AREA CODE <br /> —c'Tv'�,1�+ <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME � � rCARE OF ADDRESS INFORMATION Y <br /> MAILING OR STREET ADDRESS ✓ Gox to Indlcats INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY <br /> g 'CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME W c w• STATE ZIP CODE PHONE 70 WITH AREA GORE <br /> 6_ 6 [�l!"Ll 2 <br /> ����- WNEA INFORMATION-(MUST BE C ' <br /> NAME <br /> �OjFOWNER CARE OF ADDRESS INFORMATION <br /> MALI OR STREET ADDRESS ✓ M.mi—atl IINDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> n � e;'—r l CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY ypMEl• STATE ZIP CODE PHONE a WITH AREA CODE <br /> 11 te <br /> IV,BOARD OF EQUALIZAI UST STORAGE FEE ACCOUNT NUMBER-Call(91 6)32&Jbb9 ii questions arise. <br /> TY(TK) HQ 4 4- - p L e-1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boxbindkate 1 SELF-INSURED i1 2 GUARANTEE 3 INSURANCE C 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT D 6 EXEMPTION s9 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 INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTVFICATIONS AND BILLING: L 0 it.[_j III.X <br /> THIS FORM HAS BEEN COA4ETED UN ER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED F,SIGNED) A&iOWNER'S TITLE DATE MONTH/DAYIYEAR <br /> L� oma ' ' zl` <br /> LOCAL AGENCY USE ONLY <br /> COUNTY tt JURISDICTION# FACILITY� <br /> LOCATION CODE •OPTIONAL CENSUS TRACTS -OPTIONAL SUPVISOR•DISTRICT CODE -OP71IONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMrT 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 REGULATMpNB FOR0037A•R7 <br /> FORM A(3+'93) 9 9 <br />