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STATE OF CALIFORNIA i s co <br />STATE PLATER RESOURCES CONTROL BOARD F <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A1�4��,��y•- ago <br />COYPLETE THIS FORM FOR EACH.WCILrrYt ITE <br />1 NEW PERMIT RENEWAL PERMIT <br />MARK ONLY _5 CHA 0 P ANENTLY CLOSED SITE <br />ONE ITEM ^! 2 INTERIM PERMIT a AMENDED PERMIT � 6 TEM ARY E C101:3 -L Cf L <br />r ` / <br />I. FACILITY/SITE INFORMATION A ADDRFSS - 1h7u4T RF rORAPI GTGnl <br />DBA OR' CILITYNAME J NA�GQFOPERATQB_ <br />AD ESS <br />NEARESTCROSS ST ET PARCEL 9 IOPTIONAQ <br />�- <br />CiTY <br />i STATE EZIP C E SITE PHONE e WITH AREA CODE <br />! 11:752-03 <br />✓ aox <br />TO INDICATE COR ATION INDIVIDUAL 1- PARTNERSHIP <br />C LOCAL -AGENCY Q COUNTY -AGENCY STATE -AGENCY �. FEDERAL -AGENCY <br />DISTRICTS <br />TYPE CF BUSINESS I GAS STATION = 2 DISTRIBUTOR <br />0 ✓ IF INDIAN <br />A OF TANKS AT SITE <br />E. P. A. I. D. a (optional) <br />3 FARM a s PROCESSOR C 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />EMERGENCY CONTACT PERSON (PRIMARY) FMFRrFNrV rn NTArT 0c0enrd xo Cnnunx <br />DAYS: NAME (LAST, FIRST) PHONE b WITH AREA CODE DAYS: NAME (LAST, FIRST) <br />NIGHTS: NAME LAST, FIRS PHrN_gy; rH CODE <br />— <br />[I. <br />TI PHONE x WITH AREA COOS NIGHTS: NAME (LAST, FIRST) <br />PH z W:TN RF I?F <br />II. PROPERTY OWNER INFORMATION -(MUST BE COMPLETED <br />NAME n ., J f _ T _I CARE OF ADDRESS INFORMATION <br />�RSTREETA DRESS <br />CITY <br />III. TANK OWNER INFORMATION -(MUST BE COMPLETED <br />NAME OF OWNER i <br />✓ box to indicate 0 INDIVIDUAL ff LOCAL -AGENCY <br />`j STATE -AGENCY <br />Q CORPORATION <br />a PARTNERSHIP COUNTY -AGENCY = FEOERALAGENCY <br />ST ZIP CODE ,., PHONE M WITH AREA CODE <br />1,I Iii I, /! i lJl1'1 _X11 / r <br />CARE OF ADDRESS INFORMATION <br />MAILI OR STREET ADDRESS • a ✓ box vindicate <br />= INDIVIDUAL = LOCAL -AGENCY STATE -AGENCY <br />�;2_ 111 (✓��(�' CORPORATION = PARTNERSHIP = COUNTY -AGENCY <br />FEDERAL -AGENCY <br />CITY Nd) STA ZI CODE HONE A WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ4�4 I-� 5 Q "I <br />V. PETROLEUM UST FINANCIX RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicateL- I SELF-INSURED I— <br />J 2 GUARANTEE I1 3 INSURANCE J 4 SURETY BOND <br />C� 5 LETTER OF CREDIT J 6 EXEMPTION <br />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 ecked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />APPLICANT'S \AME (P9,.%TED E SIGNATURE) APPLICANTS TITLE I DATE MONTH,DAY YEAR <br />LOCAL AGENCY USF ONLY <br />COUNTY tt i JURISDICTION rr FACILITY I G` <br />C3 <br />---- "AT" N COD E : �'/O :AL C NSUS TRACT a - OPiICNAI - - -- ----- - -- <br />I ! SUPVISOR - DIS"RI T CODE - OPTIONAL ` : 1/1 <br />TJIc C'1n �� • ��� :� 4 " <br />• ••+•+u� r 1v1wIrAfV¢U 0 i AI LCAJ 1 III Un IVIUNt FtHNII I AHI LIGATION - I-L)KN9 B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FILE THIS FORM WITH THE L#*AGENCY 1NIPLEMENTING THE UNDERGROUND STORA*K REGULATIONS <br />FGP70i7AF <br />�`r <br />