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♦ 4• � r <br /> s <br /> STATE OF CALIFORNIA '� <br /> (•E. n STATE WATER RESOURCES CONTROL BOARD W w�' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA r <br /> L i�peY`- <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED S0 <br /> ONE REM 2 INTERIM PERMIT O 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 4111 <br /> I. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAM/E OLF OPERATOR - <br /> DBA OR FACILITY NAME IL�W /LD Q�� �N�( (`J <br /> I Aly I NEAREST CRO STREET-_ ` PARCELt(OPTgNAu <br /> ADDRESS A PrNC <br /> Z 7' STATE ZIP CODE SITE PHONES WITH AREA CODE <br /> CITY NAME G.A O CJ <br /> T I/ BOX <br /> ATE O CORPORATION INDIVIDUAL PARTNERSHIP DISTRICTS'ENCY 0 COUNTY-AGENCY' STATE AGENCY' O FEDERALAGENCY' <br /> •g owner al UST Is a public agency,wmplete the following:nacre of SupervYor W ON'mbn,seclbn,or office whk�operates <br /> IF INDIAN a OF TANKS AT SITE E.P.A. I.D.A(apliaMg <br /> TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTOR � RESERVATION <br /> O 3 FARM O a PROCESSOR � 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> DAYS: NAME(LAST,FIRST) - � _ ( / Zo9- C,(tJ <br /> G Mo,vt�0 20' `?,/L - `' sy [ PHONE WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> M F q_ l91 <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED CARE OF ADDRESS INFORMATION <br /> NAME — <br /> C}AJ <br /> STATE-AGENCY <br /> MANGR Z ✓ BoFbyaO INDIVIDUAL [j] LOCAL AGENCY <br /> STREET ADORESS <br /> CORPORATION O PARTNERSHIP COUMYAGENCY � FEDEMLAGUCY <br /> R x <br /> ZIP CODE PHONE#WITH AREA CODE <br /> CITY NAME 9520P5 209-4�/6 - SFsoo <br /> ;5-'O O <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER - CARE OF ADDRESS INFORMATION <br /> Mo Nc Mtbllon <br /> MAILING OR STREET ADDRES �✓ E/y biMkame INDIVIDUAL 0 LOCAL Q STATE AGENCY <br /> RO x 0 ZSb/ ) t ��� LQ CORPORATION O PARTNERSHIP O COUNTVAGENCY FFDEM4AGEN V <br /> CITY NAME LC/ STATE ZIP CODE PHONE a WITH AREA CODE <br /> �7-0eJC'toA1 �, 95208 Z�- 9�l6' S�Oa <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [_4]4-]-[6 2 �/ 9 / 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I/ Mc biMkale I SELF INSURED O2 GUARANTEE INSURANCE i 1 A SURETY BOND <br /> 5 LETTER OF CREDIT E]6 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: I.O II.[W III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'SNAME RINE SIGNED) O R'S TITLE DATE' MONTWDAV/YEAR <br /> — CEO <br /> LOC#L AGENCY Utt ONLY <br /> COUNTY x JURISDICTION# FACILITY# <br /> 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT♦ -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT AppucATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGANKULATKM FaRom6AI <br /> FORMA(393) (j <br /> A� <br /> l 1�9i <br />