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a % <br /> W o <br /> STATE OFCAUFORNkIA Y �p <br /> W Yl 1M C <br /> STATE WATER RESOURCES CONTROL BOARD ams 7 a Q <br /> PERMIT APPLICATION <br /> UNDERGROUND STORAGE TANK - FORMA c,l6�a�N5• <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE <br /> 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION � 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> 1 NEW PERMIT PERMIT 6 TEMPORARY SITE CLOSURE o <br /> ONE ITEM � 2 INTERIM PERMIT 4 AMENDED <br /> I, FACILITYISiTE INFORMATION 8,ADDRESS-(MUST BE COMPLETED) <br /> AME OF OPERATOR <br /> DBA OR FACILITY NAME PARCEL it(OPTIONAL) <br /> NEAREST GROSS STREET <br /> ADDRESSCODE <br /> STATE ZIP CODE SITE P-HON #WITH AREA <br /> CITY NNAME CA 1/ 7� <br /> LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE•AGENGENCY' Q FEDERAL-AGENCY' <br /> ✓ BOX Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q DISTRICTS' <br /> TO INDICATE <br /> late the lollowln name of Supervisor of dry sksn,Becton,or atitce w'h c�71 NDIANatese #OF TANKS AT SITE E.P.A. I.D.#(oPlionef) <br /> LIST <br /> It owner d UST Is a public agency,comp B' <br /> TYPE OF BUSYNESS 1 GAS STATION 2 DISTRIBUTOR <br /> Q RESERVATION <br /> 3 FARM Q 4 PROCESSOR �5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> EMERGENCY CONTACT PERSON (PRIMARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> PHONE#WITH AREA CODE <br /> DAYAM'E <br /> (LAST.FIRST) v,) �/w5;1` PWONE#WITH AREA GODS <br /> G� r�Y 4o PHONE#WITH AREA GO NIGHTS: NAME(LAST,FIRST) <br /> NIGHTS: NAME;LAS FIRST) ^�-7 f <br /> II. PROPERTY OWNER INFORMATION` MUST BE COMPLETE,.D.� CARE OF ADDRESS INFORMATION <br /> NAME <br /> r f ,/ box plydicate 0 INDIVIDUAL (] LOCAL-AGENCY Q STATE-AGENCY <br /> CCUNTY-AGENCY FEDERAL-AGENCY <br /> MAILING OR STREET DRE Sir CORPORATION [] PARTNERSHIP Q [� <br /> STATE ZIP CrOD J PHONE#WITH AREA CODE <br /> CITY NAME ( �� <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME OF OWNER �fV J1 <br /> �/ box to Ind cake <br /> INDIVIDUAL Q LOCAL-AGENCY QSTATE-AGENCY <br /> MAILING OR STREET <br /> �A-D�ADDRESS f y-A-4 .T— 0 CORPORATIONS C� PARTNERSHIP =COUNTY-AGENCY CJ FEDERAL-AGENCY <br /> ([.'! I d Z- / STATE, ZIP CODE P ONE#WITH AREA CODE <br /> CITY NAME L-/!tel' <br /> c,;�> 1G L <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-966 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)--IDENTIFY THEE MES)BOD(S) USED ANILA =SIURETY 1 SELF-INSURED Q 2 GUARANTEEbox lolndicale Q6 EXEMPTION Q �OTHER <br /> 5 LETTEROFCREDIT <br /> Vi. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank;owner unless box I or ll is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE'I TRUE AND MO CORRECT <br /> OWNER'S TITLE <br /> OWNER'S NAME SPRIN11 TED&SIGNED) <br /> 111111111111 <br /> LOCAL AGENCY USE ONLYFACILrTY x <br /> COUNTY# JURISDICTION# <br /> SUS TC7# •OPTfONA1 S VIS�OR.DISTRICT CODE -CPnONAL <br /> -OPTIONAL 312 <br /> LOCATION CODE � <br /> a <br /> z 9 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMR APPLICATION- FORM B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> NG THE UNDERGROUND STORAGE TANK REGULATK?NS <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTI � _ <br /> FORMA(31931 <br />