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4 <br /> STATE OF "`'.- .° <br /> r STATE WATER RESOURCES CONTROL BOARD <br /> ` UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A �® <br /> COMPLETE THIS FORM FOR EACH FACti.ITYISr E <br /> MARK ONLY CO I NEIN PERMIT ❑ 3 RENEWAL PERMIT ❑ s CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED.SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT Q 4 AMENDED PERMIT ® B TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME J NAME OF OPERATOR <br /> ADDRESS _ N EST/CROSS STREETn PARCH o(OPTIQNiAL) <br /> a7 7 �t r v� rc., 1 L�G <br /> CRY NAME STATE ZIPCODE SITE PHONE#WITH AREA CODE <br /> ✓BOX r0 CORPORATION ®NWDJX p PAmmmr ® ®COUNTY•AG9ICY• p STATE-AGENCY <br /> TO TE p R�ERAL AGEtdCY <br /> •e ovw*I USTb&pAft agmW. #w+o9owrq=no d vAmvw d ftsim.action aroffmwhich opmm Me UST <br /> TYPE OF BUSINESS 0 9 GAS STATION ® 2 DISTRIBUTOR ® ✓IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(quVamQ <br /> 0 RESERVAT <br /> ION <br /> 3 FARM ® 4 PROCESSOR ® S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS NAME S1 .FlR E i WITH AREA CODE GAYS NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> ^�rtr,T 2+�i (1� 6S7-S&S <br /> NIGHTS. NAMEILAST.FIRST) PHCFVE i WITH AREA CODE NIGHTS; NAME&AZT,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME ,+ CARE OF AD EBB INFOFIMATTON <br /> MAILING OR STREET ADDRESS ✓ be m, p MM MAL ®LOM AM= p STATE-� <br /> +,�.L7 1 l? 1 CZ TION p P ®COIRRY4WCY p F8XRALAMNCY <br /> CITY NAME STATE 21P CODE PHONE4 WITH AREA CODE <br /> [?,7o�� ix 7t�V1 -0-711 5EEZ J`.G <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NtANAE OF OWNER I . CARE OF ADDRESS INFORMATION <br /> /r, �V,^i-1--y" !' 1 Lm, ' L--ter"+- DeMintflo <br /> MAILING OR STREET ADDRESS ' ✓ bcc to n#a# p 9DMWAL p LocAL•AGENCY p smn-AGENCY <br /> —i/' Q CORPORATION p PARTNERSHIP ®collNTr-AGe4CY p RE?ERALAZE= <br /> CRY NAME ST T,E/ ZIP CODE PHONE I WITH AREA CODE <br /> 1 -071 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Can(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4� I I <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> r ® + O 2 WAMWE p 3 INSURANCE p 4 SUNY SOM CK s LETTER OF CREDIT p e EX wncN p 7 STATE FUND <br /> E.D.e STATE Rm&Offw mANcm OFRCER LETTER p 9 STATE RIND&csmFr-ATE ® io LOCAL GoYT mHANism p m oTNER <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 SILUNG: 1.❑ II.❑ IIL <br /> 7MS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR <br /> '.�'. cP^'....'-i�... � G'i:'$.�" '.�--•if''�� ��/%.L/ �.�/_.�i�`.:/+-+A-/+° T'��."' 1� ;V` �w�"Z� � � 1 I� <br /> LOCAL AGENCY USE ONLY ✓ /// <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION 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, <br /> UNLESS IS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) <br /> OWNER MUST FILE THIS FORM E LOCAL AGENCY IMPLEMENTING THE UNDERGROUqVRAGE TANK REGULATIONS <br />