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7. <br /> Nw­ <br /> i ,. �-. ': ;': PQ' • Cp ate' <br /> o STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> �h <br /> COMPLETE THIS FORM FOR EAC ACILITY/SITE <br /> MARK ONLY F I NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2"INTERIM PERM 1 4 AMEN D PERMIT TEMPORARY'-3TFE-ELOSUR ' <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> Fofft <br /> DBA FACILITY NAME NAME OF OPERATOR a <br /> "SV MqA1 <br /> DRESS - NEARESTICROSS STIRWT PARCEL#IOPTIONAL) <br /> } <br /> trrY NAME _ STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ej CA <br /> BX <br /> TOINDIO TE O CORPORATION 56INDIVIDUAL PARTNERSHIP (� LOCAL-AGENCY COUNTY-AGEN STATE-AGENCY FEDERAL-AGENCY <br /> ��.• DISTRICTS ` <br /> TYP F BUSINESS 1 GAS STATION 2 DISTRIBUTOR o ✓ IF IN AN #OF TANKS AT SITE E. A. 1.D. (optional) <br /> w.' RESERV ' ION <br /> ,. 3 FARM 4 PROCESSOR5 OTHER OR TRUST L DS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGE (SECONDARY)-optlonal f�►, <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) �^Ip EI.1'7 0f, t4 <br /> NIGHTS: PIAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br />� t U .14 1-7 A CODE <br /> PHONE WITH AR <br /> � <br /> il. PRO.ERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ✓ box to indicate <br /> MAILING OR STREET ATS RES$ 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> Aj CORPORATION � PARTNERSHIP � COUNTY-AGENCY <br /> FEDERAL-AGENCY <br /> a. <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> . <br /> ' 11. TANK OWNER INFORMATION MUST BE COMPLETED) <br /> t <br /> x NAME OF OWNER / CARE OF ADDRESS INFORMATION <br /> ;"'tt4— <br /> MAILING <br /> .,' <br /> - MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 6)323-9555 if questions arise, :; <br /> TY(TK) HQ 4 4 - Q �( C� <br /> W,PETROLEUM UST FINANCIA ESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boxbhHdCate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETYBOND <br /> 5 LETTER OF CREDIT 1�6 EXEMPTION 99 OTHER <br /> VI. LEGAL::NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner less box I or II is chgoked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. it. III.= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT sy <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> Al- <br /> LOCAL ACENCYUSE ONLY - <br /> COUNTTY# JURISDICTION# FACILITY# Nl I <br /> / � f 0 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 4j OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANC;gE� �..�E INFORMATION ONLY. X <br /> FORM A(5-91) FOR0033A 5 <br /> (�( <br /> v <br />