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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FO <br /> � <br /> COMPLETETHIS FORM FOR EACH FACILITY,SITE <br /> a.... <br /> MARK ONLY Q I NEW PERMIT O S RENEWAL PERMIT S CHANGE OF INFORMATION LY CLOSED SITE <br /> ONE ITEM 7_1 2 INTERIM PERMIT a a AMENDED PERMIT S TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NASME <br /> /W NAME Of OPERATOR <br /> /lM ! <br /> ADDRESS NEAREST CROSS STREET PMCEL ry0FTI0NAU <br /> CITY NAME STATE <br /> CA 21P CODE71e,` <br /> CA <br /> SITE PHONE 0 WITH AREA CODE <br /> I/ BOX <br /> TOINDICATE Q CORPORATION Q INDIVIDUAL Q ARTNERSNIP Q LOCAL-AGENCY Q COUNTY-AGENCY �j Q STATE-AGENCY Q FEDERAL AGENCY <br /> 06TMCTS <br /> TYPE OF BUSINESS O I GAS STATION o 2 DISTRIBUTOR Q ✓ IF INDIAN Y OF TANKS AT SITE E.P,A. L 0.#(optimal) <br /> PESERVATION <br /> O D FARM Q a PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) <br /> PqCNF a WITH AACA <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓Ooa bvbkan Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATICN Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa bilbba# Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGEVCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION <br /> �UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 -j d 1.3 L�7F_0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box bbkbal# Q I SELF-INSURED Q 2 ANTEE QT)INSURANCE <br /> Q A SUFETY 17ND <br /> Q 5 LETTER OF CREdT jaS EXEMPTION Q 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: I,= II.D III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME IPRINTED 6 SIGNATURE) APPLICANTS TITLE DATE MONTWOAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTIONA FACILITY <br /> M5or = 1—Ir-111 <br /> —/ / 1/ <br /> LOCATION CODE - ONAL (CENSUS TRACT# -OPIIONAL ISUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE (i)OR MORE PERMIT APPLICATION- FORM S,UNLE IS IS A CHANGE OF SITE INFORMAT;GN ONLY. I <br /> FORM A(5-91)� FCR0033A 5 <br /> 1 <br />