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.k�i�ftJlN C.O. Lf{7Ce--Of ��t7`��I�f� <br /> STATE OF CALIFORNIA �+ n <br /> Z22 C•WEy'XyC. 1144'(110UI•4 <br /> To no <br /> STATE WATER RESOURCES CONTROL BOARD .. G 2 S Ir , <br /> '.9520) UNDERGROUND STORAGE TANK PERMIT APPLICATI P�M N T AIle un <br /> If <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F__] 3 RENEWAL PERMIT [::] 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CL ro <br /> 7/ <br /> ONE ITEM E 2 INTERIM PERMIT 0 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA O FACILITY NAME N ME OF OPERATOR <br /> s ue, Qv1"mlS'� f nl 4 A4w� 561(+4CL-S,)r-&, <br /> ADDRES NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 960 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> _rfAcy CA (0 v <br /> ✓ BOX CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY Q COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORI/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM a 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME- (LAST, <br /> F�IRRSSTT)� PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> pow dGfJ�ai[ <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME — — CAR€OF ADDRESS INFORMATION <br /> MAILIN OR STREET ADDRESS ✓ box indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> ,(, , 5 c4 CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ca9- 'f�3r DBo� 5 Pzgj <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> f/ j co, l we(_ <br /> MAILIN OR STREET ADDRESS ✓ bo indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION (] PARTNERSHIP COUNTY-AGENCY = FEDERAL-AGENCY <br /> CIN NAME STATE _FZIP CODEHONECODE <br /> �*3^of d/ P��#WITH�6 Z.9' <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ F4-F4]-101 I tjjjjt� <br /> V. PETROLEUM UST FINANCIAL R ONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1 SELF-INSURED 0 2 GUARANTEE = 3 1NSURAN 0 4 SURETY BOND <br /> =5 LETTER OF CREDIT O 6 EXEMPTION 0 99 OTHE <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank o er unless box or II is checked. <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.& I.D III.= = <br /> THIS FORM HAS BE NDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLED ,IS TRUE ID CORRECT <br /> APP ANT'S NAME L(PRIaNTE &SIGNATU APPLICANTS TITLE ONTHlDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# 01 FACILITY# �Z <br /> VI tev x - <br /> LOCATION CODE •OPTIONAL CENSUS TRACT# -OPTIONAL SUPVI,S�OOR-DISTRI T CODE -OPTIONAL <br /> G— s <br /> THIS FORM MUST E 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 /> 64 <br />