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fey°uacer c <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a t <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> • ��[rr pry N� <br /> I COMPLETE THIS FORM FOR EACH FACILrrY1SITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION n 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION &ADDRESS-(MUST BE COMPLETED) _- <br /> DBA OR FACILITY NAME / NAME OF OPERATOR ` p <br /> ii <br /> ADDRESS NEAREST CROSSL STREET PARCEL#(OPTIONAL) <br /> CITY NAME ! STA E ZIP CODE: SITE PHONE#WITH AREA CODE <br /> y <br /> TO INDICATE CORPORATION [ INDIVIDUAL PARTNERSHIP ] LOCAL-AGENCY COUNTY-AGENCY F STATE AGENCY [ FEDERAL-AGENCY <br /> CISTRICTS <br /> TYPE OF BUSINESS mit 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D-#(optional) <br /> RESERVATION <br /> 0 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) -(7 r <br /> _ _ 6_ ! -Ar r C. <br /> PHONEz-wII <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION. <br /> X111 fl�t�Cr-T LJ IAt <br /> MAILING OR STREET ADDRESS ✓ box lo indicato 2j?'1NDIVIDUAL ] LOCAL-AGENCY STATE-AGENCY <br /> L �p"y _ 0 CORPORATION =P.ARTNERSHIP � COUNTY-AGENCY ®FEDERAL-AGENCY' <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> k 620, <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED_) <br /> NAME OF OWNER I I L CARE OF ADDRESS INFORMATION <br /> - tM r 4 +-,t\ D V 1 <br /> MAILING OR STREET ADDRESS ✓ box to indicate (�INDIV'IDUAL O LOCAL-AGENCY STATEAGENCY <br /> j 1 W-- S- �pt� 7]CORPORATION F--] PARTNERSHIP' [] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP GORE PHONE#WITH AREA CODE <br /> C7 A e 61 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 14]-L�� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ NX to Indu;at6 I SELF-INSURED 2 GUARANTEE V-3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT I E EXEMPTION CI 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 SHO t7,LD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 1. III.F71 <br /> TH)S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PR INTER ti SIGNATURE) n APPLICANT'S TITLE DATE MONTHIDAYNEAR <br /> ( A," <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> r FT <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISO R-DISTRICT CODE -.OPTIONAL x <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 /> FORM A I12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A.R6 <br />