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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD ' .;.0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION FORMA <br /> (/ COMPLETE THIS \ ^ W <br /> r—� 3 RENEWAL PE T O 1 FORMATION 7 PER CLOSED/TE LY <br /> MARK ONLY t NEW PERMIT <br /> ONE ITEM 2 INTERIM PERMIT <br /> A AMENDED PERM a MPORAR ITS CLOSUR <br /> � <br /> I. FACILITYISITE INFORMATION &ADDRESS-(MUST BE COMPLETED) <br /> NAME Of OPERATOR '` <br /> ORA OR FACILITY NAME C / I+ I6U <br /> PY1"^� t, 7 NEAREST CROSS 57REET I POONAU 1WJ1v <br /> ADDRESS �J/ /w/ A G 7J I `D STATE ZIP C E SITE PHONE a WITH AREA CODE <br /> CITY NAME ` l (/V /7 _� —. 973 �G <br /> TOIN BOXL7 <br /> rJ CORPORATION C INDMOUAL O PIATNERSNIP O DIST CTS�Y ED COUNTY-AGENCY O STATE-AGENCY �FEDERAL <br /> ./ IF INDIAN a OF TANKS AT SITE E.P.A. L 0.0(aPOW0 <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESERVATION <br /> Q 3 FARM O A PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON <br /> (SECONDARY)•optlanal <br /> 7NIGHTS: <br /> (LAST,FIRST) PHONE A WITH AREA CODE DAYS: NAME(LEFEIR <br /> PHONE Y WITH AREA CODE NIGHTS:NAME <br /> E(LAST,FIRST) u aApp A COO <br /> if. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME <br /> W III rld � Q INDIVIDUAL LOCAL-AGENCY J STATE-AGENCY <br /> MAILING OR STREET ADDRESS GI CORPORATION Q PARTNERSHIP O COUNTY AGENCY IE3 FEDERAL-AGENCY <br /> STATE I ZIP CODE PHONE+I WITH AREA CODE <br /> CITY NAME <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER <br /> ✓ �^i n'v9cw Q INDIVIDUAL 0 LOCAL-AGENCY <br /> MAILING OR STREET ADDRESS STATE-AGENCY <br /> Q CORPORATION D PARTNERSHIP )�COUNTY»LGENCY a FEDERALAGENCY <br /> STATE ILP CODE PHONE N WITH AREA CODE <br /> CITY NAME <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4774 - b 2 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED A ARE vmNo <br /> I SELF INSURED O 9 GUARANTEE i� 3 INSURANCE O <br /> ,/ COAoiMew Q 5 LETTER OF CREDIT Q 9 EXEMPTION 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.❑ 11.❑ III- <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS TITLE DATE MONTWDAYNEAR <br /> APPLICANTS NAME(PRNTED 6 SIGNATURE) /_// _�•") <br /> LOCAL AGENCY USE ONLY _ F% � <br /> COODU�NL�.TTY_1�# JURISDICTION x FACILITY a <br /> OL <br /> / <br /> LOCATION CODE -OPTIONAL CENSUS TRACT I -OPT30NA SUPVISOR- ISTRK;T CODE -OPTIONAL <br /> 00 THIS M MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,U OF srrE INFORMATION ONLY. <br /> FORDMA 5 <br /> FORM A(S-91) <br />