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w <br /> f �V�RR C <br /> STATE OF CAUFORWA M1oc t <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT B TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> } -ID41 LAI+ r <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> 1 1 a U n0- 17,9 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> -ack}�r� CA <br /> ✓ BOX <br /> TO INDICATE CORPORATION 0 INDIVIDUAL E�]PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' = 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 <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTORFORTRUSTLAND <br /> ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION nn <br /> 3 FARM 4 PROCESSOR Q 5 OTHERSCAL 0 3 6 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DS:NAME(LAST,FIRST) PHO E#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> n <br /> 11 a Q- -t-,311 t M1 r 4 36&- 1p <br /> IGHTS:'NAME(LMT,FIRS PHONr#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1 d CO Z - 1513 maret n 200 A4 2 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION � <br /> Y 1 h f 2 Of +1 Gm t Av it ' <br /> MAILING OR STREET ADDRESS ✓box blndicate INDIVIDOAL LOCAL-AGENCY STATE-AGENCY <br /> LC; .1-x(1 L`� CORPORATION PARTNERSHIP 0 COUNTY-AGENCY ED FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 0.00m m a bz%llpkp <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Utl�ramav- Ync, ;:nrr4 U inru <br /> MAILING OR STREET ADDRESS �s✓S box to indicate INDIVIDUAL (� LOCAL-AGENCY 0 STATE-AGENCY <br /> Z5 -k Th�r4 ee,} KOORPORATION PARTNERSHIP E:1 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME ,F STATE ZIP CODE PHONE#WITH AREA CODE <br /> 144x" "A CA 0 - z�+ <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - ()1 Z 4O <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED - <br /> ✓ box ID indicate E�Ej_d SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> =5 LETTER OF CREDIT 6 EXEMPTION Q 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: 1.0 11.❑ III."-. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# 3�3 o rly✓' <br /> vV <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST°E ACCOMPANIED BY AT (1)OR MORE PERMIT APPLICATION- FORM B,uNLEMIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR. THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS <br /> FORMA(3/93) FOR0033A-R7 *{'` <br /> �__A <br />