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/� gOVR e <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD p <br />UNDERGROUND STORAGE TANK PERMIT APPLICATIOR RMA, ,,,. a <br />1V� IIFUMN' <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE /�/\, <br />MARK ONLY _F-1 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERNWJ!'�'iFLY CLOSED SITE <br />ONE ITEM ( yQ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �'(J T <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAM <br />kmo 'Fac uAlb <br />NAME OF OP <br />1< N �eNrvQeS ,1vc. <br />ADDRESS <br />��caS `rRae P�\va <br />NEAREST CRO <br />C�ov� <br />NIGHTS: NAME (LAT FIRST) PH NE ITH AREA CODE <br />Cha e. C• PH(NE as,-swo <br />CITY NAME <br />STATE ZIP CODE <br />SITE P1ik0NE # WITH AREA CODE <br />ZIP CODE <br />alb'10�- 1003 <br />CA S <br />2bq it s -'too S <br />✓ BOX CORPORATION INDIVIDUAL 0 PARTNERSHIP 0 LOCAL -AGENCY 0 COUNTY -AGENCY STATE -AGENCY 0 FEDERAL -AGENCY <br />TO INDICATE sm <br />DISTRICTS <br />TYPE OF BUSINESS EW 1 GAS STATION 2 DISTRIBUTOR/ <br />IF INDIAN I# <br />OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM 0 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FLRST) PHONE WITH AREA CODE <br />3s Ako S <br />01 <br />DAYS: NAME (LAST, FIRST) too - Z„1IL - (PIA <br />1Q FL <br />A %v"%NTe <br />0 <br />o n�o*c. <br />NIGHTS: NAME (LAT FIRST) PH NE ITH AREA CODE <br />Cha e. C• PH(NE as,-swo <br />NIGHTS: NAME (LAST, FIRST) �� <br />It <br />II. PROPERTY OWNER INFORMATION - MUST BE COMPLETED <br />NAME W <br />Wk `1 t��uc C v , <br />CA DRESSINFORMATI;,;+7t <br />EN 'q fn - Co c <br />MAILING OR STREET ADDRESS <br />✓ Ph4Qcate IN -AGENCY 0 STATE -AGENCY <br />✓ box to indicate = INDIVIDUAL <br />[X CORPORATION 0 PARTNERSHIP <br />Pe CORPORATION 0 PARTNERSHIP = COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />CA <br />ZIP CODE <br />alb'10�- 1003 <br />PHONEWITH AREA CbME-.----. r - <br />� 1010-Syv`l `-` <br />S\ <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER r <br />A1'Z,W P�ry V c C U • <br />CARE OF ADDRESS INFORMATION <br />CNV . Co tr \ �aMR� <br />DATE O/N� H/DGAYNEAR <br />MAILING OR STREETDRESS <br />�, o , 6. 1ao <br />✓ box to indicate = INDIVIDUAL <br />[X CORPORATION 0 PARTNERSHIP <br />= LOCAL -AGENCY 0 STATE -AGENCY <br />Q COUNTY -AGENCY = FEDERAL -AGENCY <br />CITY NAME ��-cess <br />STA <br />IP CODE <br />� <br /># WITH AREA JBODE- -- <br />%,%A1 610 -Su <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if <br />TY (TK) HQ K41-1 ol ol o IS o b <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br />5 LETTER OF CREDIT 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. 0 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) AA,�,,A�APPLJCANTS <br />TITLE <br />DATE O/N� H/DGAYNEAR <br />LOCAL AGENCY USE ONLY <br />I <br />COUNTY # \ / JURISDICTION # FACILITY # I <br />ILOCATION 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 INFORMATION ONLY. <br />FORM A (5-91) FOR0033A-5 <br />