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E <br /> 8 <br /> t• W�4• C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERM APPLICATION-FOA]M'A •i <br /> COMPLETE THIS FORM FOR EA FACILITY/SITE <br /> MARK ONLY D 1 NEW PERMIT F-1 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F-�"7P(.P1'(�IErIT9Y E 1 <br /> ONE REM 0 2 INTERIM PERMIT F-1 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE s <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA��¢�@)FA�LCI�LI�N NAME '�; NAME O ERATOR JX <br /> �' 1\ S <br /> ADDRESSNEAREST CROSS STREAT PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> /eJk�jJ I CA 53106 2or - 5"-L-zs <br /> TOINDIC TE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY' Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If owner of USBOXT is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN J#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> IF <br /> 194L- <br /> /3 FARM Q 4 PROCESSOR 5 OTHER OR TRUST LANDS CWGY�-9 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> NAF!, DE . DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> ST <br /> G <br /> O- s - �<✓1tf`FI �t1LK 510-�5 -$soy <br /> NIGHTS: NAME(LAST,FIRST) NIGHTS: NAME(LAsT,FIRST) PHONE#WITH AREA CODE <br /> lu 1-0 -5'17- 1F0 7h 'K <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAM /^ Te a0s //L)C- CARE E INFORMATION <br /> MAILI OR STREE J DRESS ✓ box to Indicatee' Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> lo CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITYNnME STATE ZIP CODE PHONE#WITH AREA CODE <br /> FAENvKbt,)T- C, 9��3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAbig COF k ER � CARE OF ADDRESS INFORMATION <br /> MAILING OR STRUT ADDRESS ✓box b indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> pp O IOx CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STA ZIP CODE �- PHONE#WITH AREA CODE <br /> /2[lylC>iU/ y 3 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -101 '&1'1 lv 3❑ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box to indicate Q 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 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 if.a Ill <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&S NED) n OWNER'S TITLE DATE MONTH/DAY/YEAR <br /> lAp, 6 <br /> LOCAL AGENCY US ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> a# ® f- 1y —� <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,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) � � J�/ � ifOfl0037Afl7 <br /> Ilk <br />