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eo�R e <br /> e <br /> - STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ►,''.' <br /> C MPLETE THIS FORM FOR EACH F ITY/SITE 93 CaT <br /> MARK ONLY F__] 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANWLY CL6S*C <br /> ONE ITEM a 2 INTERIM PERMIT V4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA O F TYYeAn n' NAND Of� �TOR <br /> a Ci, I OC/i 1L� <br /> ADDRESS © �) 1 NEAT CROSS STRE PARC #(OPTIONAL) <br /> l/I►��J Iir I ;k <br /> CITYSTATES !qODE� eG)(/SIT PH'}ONE#WITH AREA CODE <br /> I/ /BOX S <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS A SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> O 3 FARM 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(L T,FIRST) . ��-2� n_ 3 <br /> c[ (J IzQ <br /> NI S: NAME(LAST,FIRST) PHONE#WITH AREA CODE N HTS: NAME(L ST,FIRST) QO� n /3'1 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM CARE OF ADDRESS INFOR ION <br /> MAI OR STREE DDRESS ✓ box icato INDIVIDUAL LOC -AGENCY TATE-AGENCY <br /> ` �� (� ORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY ME � SJ.(1Tfx ZIP CODE - �O� �� If WITH�EA CODE <br /> r It l/�' 0 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF OWNER CARE O�F`ADDR SS INF RMATIO <br /> IQ rn Cco emV r 'I <br /> MAILING OR STREET ADDRESS ✓ box 'dlc to INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> _ x CORPORATION PARTNERSHIP = COUNTY-AGENC Q FEDERAL-AGENCY <br /> CITY NAYE STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF E UALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 41-10101 Q. p <br /> V. PETROLEUM UST FINANCIAL PONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate OEX SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> O 5 LETTER OF CREDIT 0 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.= it.= III. <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 MO H/DAY/VEAR <br /> . CR �rtr n on I aAt/—,— end'. ssi"J 10 I <br /> LOCAL AGEN USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -Ob NAL CENSUS TRACT#fRIONA,Lt SUPVISOR-DISTRI DE -[PTION7 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)ORrMORE PERMIT APPLICATION- FORM B,UNLESS HI IS A CHANGE OF SITE INFORMATION 0 Y. <br /> FORM A(5-91) OR 33A-5 <br />