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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED.SITE O <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) ' <br /> DBA OR FACILITY NAME NAME OF OPERATOR L <br /> FVO,N�C, Ne s4tIp 0 V CUtlV%� <br /> ADDRESS N REST CROSS STREET PARCEL#(OPTIONAL) <br /> �07� t� yore � ,c Aver 0 0, W A <br /> CITY NAMESTATE ZIP CODE ISITE PHONE#WITH AREA CODE <br /> Ma^4Qro. CA 9575 <br /> ✓BOX 0 CORPORATION INDIVIDUAL 0 PARTNERSHIP (]LOCAL-AGENCY 0 COUNTY-AGENCY' []STATE-AGENCYFEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS <br /> 'H owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ✓IF INDIAN It OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY2S: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE <br /> �#WITH AREA CODE <br /> A- 250 <br /> cl 229 <br /> NIGHTS: NAME(LASY,FIRST) PHONE#WITH AREA CODE _ NIGHTS: NAME(LAST,FIRST) PHO #WITH AREA CODE <br /> wi ?.5 f^n S O <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> FYa k G'A; <br /> MAILING OR STREET ADDRESS \' ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> )o7 v W - ]O S P VIN t-e Ave O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> I�AWkP( i� ,� 9533 7 t�'�_)`,. 3, - 9573 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER may' CARE OF ADDRESS INFORMATION <br /> yy'' k <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ,)0 7 W JOSP m r e / tie =CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 94Um4ee- 95337 2u9 - 39A575 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> E TY(TK) HQ 4 4- - <br /> I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 0 1 SELF-INSURED =2 GUARANTEE 0 3 INSURANCE =4 SURETY BOND =5 LETTEROFCREDIT 0 6 EXEMPTION 0 7 STATE FUND <br /> 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND&CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM 0 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: t.tt_1 IL❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR <br /> LOCAL AGENCY USE ONLY T5_777 T <br /> COUNTY# JURISDICTION# FACILITY# <br /> m a 31 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> H 7x ) <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE (1)OR MORE PERMIT APPLICATION- FORM B,UNLESS S A CHANGE OF SITE INFORMA ION ONLY <br /> FORMA(6-95) . <br /> OWNER MUST FILE THIS FORM V1'HE LOCAL AGENCY IMPLEMENTING THE UNDERGROUNWRAGE TANK REGULATIONS ldfvc)A 6 <br />