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} • 'OUR e <br /> STATE OF CALIFORNIA z' <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑-5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> MARK ONLY <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA tA�CI�ITYI SIAM+E NAME. OPERATOR <br /> ADDRESS _ NEAREST CROSS STREET PARCELN(OPTOL44 <br /> CITY { ✓ ' STATE I ZIPPDE 817E PHONE#WITH AREA CODE <br /> �jf CA <br /> 1/1 TO INDICATE ATE f�J�%ORPORATION 0 INDIVIDUAL �PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCYSTATE-AGENCY. M FEDERAL-AGENCY• <br /> DISTRICTS' <br /> If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST a <br /> TYPE OF BUSINESS. ❑ 1 GAS STATION 0 2 DISTRIBUTOR a ✓ IF INDIAN #OF TANKS AT SITE I E.P.A. I.D.#(optional) .1 <br /> RESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 2�6 OTHER OR TRUST LANDS <br /> �I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> PAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME ST,FIR T) PHONE#WITH AREA CODE <br /> M etcCON11ZOL 4!=6 7fb.¢j4i• 1177 <br /> NIGHTSI�gT,FJtZSn� PHONE a WITH AREA CODE NIGHTS:NAME_ (LAST.F�i8T) PHONE x WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION, MUST BE COMPLETED <br /> NANFp CARE OF ADDRESS INFORMATION Kim <br /> MAILING�O�RSTREET ADDRESS _ �y✓, box b indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION 0 PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CIN NAME I STATE ZIP CtQD � PHOfN_E x WITH AREA CODE <br /> rip-r !"TL 9 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NA F F j <br /> CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS / ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> "� i�l "`"_''' '✓ ��V( .CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY E�j FEDERAL-AGENCY <br /> CITY�I ,r STS A ZIP�COD�_1"Zr� PHii1 W�HAR <br /> ` EA CODE <br /> 1zO <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)•32222-9996699 if questions arise. <br /> TY(TK) HQ 4 4- INI <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> E <br /> -b Indicate 0 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTEROFCREDIT 0 6 EXEMPTION 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: I.❑ II,❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> Al <br /> OWNER'S NAME(PRINTED 8 SIGNED) �,y OWNER'S TITLE DATE MONTH/DAYNEAR <br /> I°`�Li f'/ F(�r_ <br /> LOCAL AGENCY USE OKY <br /> COUNTY# ' JURISDICTION# FACILITY# <br /> _[LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -t71PTiONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OFSITE INFORMATION ONLY. <br /> FORKAP" OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCT IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />