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STATE OFCAUFORNA <br /> .TATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FOR':', A <br /> COMPLETE THIS FORM FOR EAC' ACILITY,SITE <br /> MARK ONLY I NEW PERMIT 9 RENEWAL PERMIT 5 CHANGE OF INFORMATION r7 7 PEAMAN LOSEO SITE <br /> CNE ITEM 1 ! 2 INTERIM PERMIT 4 AMENDED PERMIT 8 ,CIAPORARY SITE CLOSURE D <br /> I. FACILITY;SI INFORMATION& ADDRESS•(MUST BE COMPLETED) <br /> USA;;A;:ACILI Y tIAME �� NAME OF OPERATOR v <br /> �� .5 k" <br /> aCCAeSS <br /> ' /L / 'AF;EST l � PARCEL a(CPiq U <br /> CITY NAISE iSTATE I ZIP COLE`-- { S1TR P►QNE7YVITH AREA CODE <br /> ✓ BOz �� �� I -f'�9 — ?j <br /> TO INDICATE CdAPOAAT_,gN INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY <br /> 06TRICTS QSTATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESSI GAS STATION L� 2 OISTR;3UTOA Q ✓RESERVATICN IF INDIAN s OF TANKS AT SITE c.P.A I.D.s lopnmal) <br /> f� <br /> ^> > FARM C 4 PgCCESSOR L_ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRS' <br /> PHONE WITH AREA COC DAYS: NAME( S7,FI ST)CAA I wl_ 5—i <br /> NIGHTS: NAME(L T,FIR ,� r�J(//PHONE t WIT76H AREA6CODE NIC,HTS: �NAME(LAST, ST) <br /> OuCNc t 1,4/ITW AREA M11c <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPL ED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MA;L!`.GORSTREET AOC ESS I ✓ Dox owv".6 (1 INDIVIDUAL Q LOCAL-AaNCY Q STATE-AGENCY <br /> Q CORPCRATION Q PARTNERSHIP Q COUNrY•AGENCY Q FEOE;AL-AGENCY <br /> CITY NAME STATE I ZIP CODE I PHONE s WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> .NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET AeZRESS ✓ b310"raw Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> Q CORPORATION Q PARTNERSHIP Q COUNTY.1Gc'NCY Q FEDERALAGENCY <br /> CITY NAME STATE ZIP CODE PHONE 9 WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - rJ <br /> jp <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> ✓ pox 10r4k y Q I SELF-INSURED Q 2 GUARANTEE <br /> Q ]INSURANCE Q 4 SURETY e0N0 <br /> Q 5 LETTEACFCAEDIT Q 8 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 W14CH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1• IL= III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, S TRUE AND CORRECT <br /> APPL,CANTS NAME(PRINTED 6 SIGNATURE) APPLICANTS TITLE GATE MONTWOAYNFAA <br /> LOCAL AGENCY USE ONLY <br /> COUNTY st JURISDICTION it FACILITY x <br /> LOP I I h2.1LOCATION CODE -OPTIONAL CENSUS TRACT T NAL SUPVISOR.DISTRICT CODE -OPTIONAL <br /> v <br /> THIS FCRM M ST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APO'ICATION- FORM B, UNLESS THIS IS A CHANGE OF srrE INFORMATION ONLY. <br /> FOAM A(5-4 I) <br /> FCAoo]]A-5 <br /> •r <br />