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• STATE OF CALIFORNIA e�cooece.a <br /> STATE WATER RESOURCES CONTROL BOARD o" <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA ;`��1 �o <br /> s , o <br /> C ETE THIS FORM FOR EACH FACILRYISITE "°""�� <br /> FMARKONLY ❑ 3 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION❑ B INTERIM PERMIT ❑ T PERMANENTLY CLOSED SITE <br /> ❑ 4 AMENDED PERMIT ❑ e TEMPORARY SITE CLOSURE <br /> /SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> YNAM NAMEOFOPERATOR <br /> NEAREST CROSS STREET PARCELN(OWIONAU <br /> - STATE ZIPCODE SITE PPH'ONE,WITH'AREA CODE <br /> I/ BOX Gl�rv/t CA 4t/ <br /> TO INDICATE CO PORATION INDIVIDUAL 0 PARTNERSHIP L-2LOCAL-AGENCYD COUNTY AGENCY Q STATE-AGENCY` ` <br /> DISTRICTS (� FEDERALdGENCY <br /> TYPE OF BUSINESS ❑ 1 GAS STATION O B DISTRIBUTOR ✓ IF INDIAN #pF TANKS AT SITE E. <br /> = 3 FARM O 4 PROCESSOR OTHER O RESERVATION <br /> OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) <br /> DAYS: NAME(LAST. EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> wGs tri �U - L!(my - N/ S u , <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> $ Cr nti( <br /> S G �— <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME <br /> - CARE OF ADDRESS INFORMATION <br /> S!f /hS we O. <br /> MAILING OR STpREET ADDRE ✓ did <br /> !r O K 7EV Z D INDIVIDUAL Q COUNTY-AGNCYENCY <br /> = FEDERAL-AGENCY CIN NAME CORPORATION � PARTNERSHIP [] COUNTY4GENCV OFEDERAL-AGENCY <br /> STATE6ZIP CODE PHONE#WITH AREA CODE <br /> W f (//f1w' � L,/ <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAMEOFOWNER <br /> CA77 RE OF ADDflESS INFORMATION <br /> MAIL NG GOR STREET ADDRESS• ✓ boa binOkale <br /> CO INDIVIDUAL LOCAL-AGENCY STATE <br /> ENCY <br /> CITY NAME . mc �CORPORATION = PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENC <br /> Y <br /> SPS STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF E ON UST ST A ¢--AACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) H L4 LJ O 3 2 � <br /> V. PETROLEU ESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ bax bindicate 1 SELF-INSURED = 2 GUARANTEE <br /> CI 5 LETTER OF CREDIT ED EXEMPTION [:13 INSUflANCE 0 d SURETY BOND <br /> 0 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 c ed. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> 1.0 II. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNATURE) APPLICANTS TITLE <br /> DATE MONTH/DAV/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> B>eysa4-4 <br /> IL ! <br /> LOCATIONCODE -OPTIONAL CENSUS_fRRAjT,#^_0pDONAL __ SUPVISOR-DIST RICTCODE -OPTIONAL <br /> O 6V3a3 3IdYI�/3 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE FERMI T APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 ell FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A R6 <br />