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P60 <br />u. C C <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A �a- <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br />ONE RF-1F-1EM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR F LAT'' -5 ( /) / L )-5 /1/ L4 lr _ <br />(/ <br />NAME OF OPE ATOR <br />1%11nv:_ <br />7�ADDR <br />// r <br />NEARE TCROSSST T <br />PARCEL#(OPTIONAL) <br />CIN NAME <br />STACEA <br />ZIP � / <br />SITE PH QNE <br />SiT,pTE'�' <br />ZIP CODE <br />NE <br />✓ Box <br />TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY' Q✓L FEDERAL -AGENCY' <br />CA <br />DISTRICTS' <br />If owner of UST Is a public agency, complete the following: name of Supervisor of div' ion, section, or office which operates the UST <br />TYPE OF BUSINESS Q 1 GAS STATION ❑ 2 DISTRIBUTOR <br />Q ✓ IF INDIAN <br /># OF TAN S AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM Q 4 PROCESSOR 15 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />I <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) . onttnnal <br />D S: tjAME (LA T, (RST) PHONE WITH A /C <br />/ � <br />DAY : NAME( AST, FIRS �C�✓V' <br />PHO # W T AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE #WITH AREA CODE <br />^ <br />55 �� ✓ <br />NIGHTS: NAME( LAST, FIRST) <br />PHONE # WITH AREA CODE <br />II- PROPERTY OWNFR INFORMATION - (MI1ST RF COMPLFTFDI <br />NAME <br />_ T <br />7/6 <br />CARE OF ADDRESS INFORMATION <br />✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />MAILING OR T. EET ADD SS <br />l P61 <br />^ <br />55 �� ✓ <br />✓ box to Indicate Q INDIVIDUAL <br />Q CORPORATION Q PARTNERSHIP <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAM <br />SiT,pTE'�' <br />ZIP CODE <br />P� # WITH AREA �(✓ <br />III. TANK OWNER INFORMATION. (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY <br />Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ F4]-4-] -10112-14 1 (7 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box Io Indicate Q 1 SELF-INSURED Q 2 GUARANTEE Q 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 unle� box I or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. V if. ❑ III. ❑ <br />l THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MV KNOWLEDGE, IS TRUE AND CORRECT <br />OWNER'S NAME (PRINTED & SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br />LOCAL AGENCY USE ONLY <br />COUNTY <br />JURISDICTION# <br />FACILITY # / r <br />I.L_LJJ# <br />11 <br />k 1 '7- n I I 10 /(/" <br />LOCATION CODE -OPTIONAL <br />CENSUS TRACT # OPTIONAL_ O <br />SUPVISOR- DISTICT CDOPTIONAL <br />w <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (11 OR MORE PERMIT APPLICATION - FORM B. UNLES6 THIS IS A CHANGE OF SITE INFORMATION ONLY - <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUL.ATHM <br />FORM A (3193) ,� FOR0033AR7 <br />