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f 1 CG <br /> �STATE OFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FO M A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ID 1 NEW PERMIT 9 RENEWAL PERMIT 5 CHANGE OF INFORMATION tY CLOSED SITE <br /> ONE ITEM 2 INTERIM PSRMIT Q • AMENDED! EAMIT 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DSA OR FACILITY NAME ` NAME OF OPERATOR <br /> S•� /yy/ <br /> ACCRESS ,i � � NEAR EST CROSS STREET PARCEL I(OPTIONAI,y <br /> 't777 --/AAANPS �U <br /> CITY NAME STACA ZIP CCDE,�w% SITE PHONEt WITH AREA CODE <br /> DOXY <br /> TOISMATE C7 CORPORATION C3 INOIVIQUAL ©)ARTNERSIa1F ©LOCAL-AGENCY ©COUNTY-AGENCY Q STATE-AGENCY Q FEDERALAGSNCYDISNUC ' <br /> TYPE OF BUSINESS a 1 GAS STATION Q 2 DISTRIBUTOR AE3EIAVACTIIANON •OF TANKS AT SITE E_A.A. L O.r(00mal) <br /> Q 1 FARM Q 4 PROCESSOR Q S 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 /> u <br /> NIGHTS:NAME(LAST,FIRST) PHONE m WITH AREA COPE - NIGHTS: NAME(VST.FIRST) <br /> *uQNFaWITI4 ARP4 CQQP <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING CR STREET ACORESS ✓ mY o imicze []INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY:3. <br /> ©CORPORAPCN © PARTNERSIV 0 COUNTY-AGENCY ©FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE+1 WITH AREA CODE <br />' 4 <br /> I` 111. TANK OWNER INFORMATION-(MUST BE COMPLETCD) <br /> NAMEOFOWNEA CARE OF ADORE SSINFORMATION <br />' MAILING OR STREET ADDRESS ✓ qox 10 iamcu4INDIVIDUAL <br /> p © LOCAL-AGENCY p sTATE•AGENOY. <br /> CORPORATICN PARTNERSAP C1 COUNTY-AGENCY Q FEDERAL'AGENCY <br /> CITY NAME I STATE ZIP CODE PHONE IP WITH AREA CODE <br /> i <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(9 16)323-9555 if quesUans arise. <br /> TY(TK) HQ F4-F4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPL ED)—IDENTIFY THE METHOD(S) USED <br /> ✓�Y ninOk4u [] 1 SELF-;NSUAED Q 2prMAXTEE Q 7 INSURANCE Q 4 SURETY BONO- <br /> CE 5 LETTEROFCREDIT 8 EXEUPTION © 9e OTHER <br /> i <br /> VL LEG AL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or 11 is checked. <br /> I <br /> CHECK CNE 90X INOICATINo WHICH ABOVE ADDRESS SHOULD 3E USED FOR LEGAL NOTIFICATION!AND MUM L a ILO Ila_❑ <br /> THIS FORM HAS BEEN COMFLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED a SIGNATURE) APPLICANTS TITLE - DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION a FACILITY x <br /> I <br /> It LOCATION COCE-CPTICNAL I CENSUS TRACT s -OP alONAL - I SUPVISOR•DISTRICT CCOE -OPTIGNAL <br /> THIS FCRM?,LUST 8E ACCOMPANIED BY AT LEAST'(1)OR NICRE PE�,51IT APPUCATION. FORM S,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY:' r� <br /> e � FOAM A(5.3t}� �; r FCR0077A5 ! <br />