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e� <br /> w50.R �S <br /> � Hwy P <br /> STATE OF CALIFORNIA a, <br /> STATE WATER RESOURCES CONTROL BOARD a ', <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA �, a <br /> ` � PillfoA�� <br /> Ilrr COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ONE ITEM __ 2 INTERIM PER 1 NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 1_ I 7 PERMANENTLY CLOSED St <br /> FTE <br /> 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE d J <br /> �� <br /> I, FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DRAOR FACILITY NAME %AIE OF OPERATOR <br /> Z_ -NEARE TCROSSSTREET PARCEL#(OPTIONAL) <br /> ADDRESS I / r'J <br /> '22 / � [, <br /> CITY NA STATE ZIP CODE TEP NE# TH REA CODE <br /> CA <br /> TO INDBOXYCATE 0 CORPORATION � INDIVIDUAL �]PARTNERSHIP I]LOCAL-AGENCY COUNTY-AGENCY d STATE-AGENCY I7 'FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> O RESERVATION <br /> 3 FARM 0 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) <br /> ------- <br /> ev\_l <br /> NIGHTS: NAME{LAS .FIRST] NE 9 WITH AREA CODE - NIGHTS: NAME{LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> --- � � r `- box b indicate INDIVIDUAL LOCAL-AGENCY []STATE-AGENCY <br /> MAILING OR STREET DDRESS <br /> Z7 3p� - �JG CORPORATION [� PARTNERSHIP [� COUNTY-AGENCY [] FEDERAL-AGENCY <br /> 1 CITY NAME _ f ! STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED)_ <br /> / CARE OF ADDRESS INFORMATION <br /> NAME OF OWNLRA <br /> sr/(�,(�I L !fes/ ids <br /> MAIL RS7REETADDRESS ✓ boxmindicate I7 INDIVIDUAL © LOCAL-AGENCY STATE-AGENCY <br /> Q. � f CORPORATION Q PARTNERSHIP 0 COUPQTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HO [4 1.4]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> bcx m indicate I I SELF-INSURED r1 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> I.J 5 LETTER OF CREDIT n 6 EXEMPTION 1—] 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 INDICAPNG WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.U IL l] III. <br /> X I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE} APPLICANTS TITLE DATE MONTHIDAYIYEAR <br /> I <br /> LOCAL AGENCY USE ONLY <br /> COUNTY u JURISDICTION N FACILITY# <br /> LOC:•ATION CODE OPTIONAL. CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE RMATION ONLY. <br /> POPM A(12-91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REG ULATIONC,-,e <br /> FOR13633A-R6 <br />