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� a <br /> STATE OF CALIFORteASTATE WATER RESOURCES CONTROL BOARDUNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A 4COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMITb CHANGE OF INFORMATION Q 7 PERMANENTLY C OSE <br /> ONE ITEM (] 2 INTERIM PERMITO 6 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DS&W FACILITY NAMENAMEOFOPERATOR <br /> L <br /> ADDRESS NEARESTCROSS STREET PARCEta(OPTIONW <br /> CITY NAME STATE ZIP BITE PHONE a WITH AREA CODE <br /> G, CA <br /> 701Np TE (]CORPORATION D INDIVIDUAL =PARTNERSHIP LOCAL-AGENCY Q COUNTYAGENCY' O STATE-AGENCY' O FEDERALAGENCY' <br /> OBTFUCTS' <br /> g owrwr d UST Is a pWAc agwoy,owrpWA the tolowgp:name of Supervisor of dNlebn,cectbn.ar duce which operates the UST <br /> TYPE OF BUSINESS Q 1 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN NOF TANKS AT SITE E.P.A. I.D.a(tptlulNJ <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR b OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optlorad <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE A WITH AREA CODE <br /> 0 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING oA STREET ADDRESS ✓Eubi I] INDIVIDUAL (] LOCAL-AGENCY D STATE-AGENCY <br /> Q —1f . Q CORPORATION 0 PARTNENsmP D COUNTYAGENCY D FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> c ai <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> s E ig s C,b ve . <br /> MAILING OR STREET ADDRESS ✓ bmbkNNtle INDIVIDUAL []LOCAL-AGENCY STATE- <br /> AGENCY <br /> Q CORPORATION PARTNERSHIP COUNTYAGENCY ED FEDERALAGENCY <br /> CITY NAME 9TATE 21P CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) Hp M44- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED <br /> y,t uMkale O 1 SELF-INSURED [Z)2 GUASANIEE 0 3 INSURANCE O e SURETY BOND <br /> 5 LETTEROFCREOR O S EXEMPTION Tegg OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I Or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNERSTfRE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY FAC- .I D 047w- .j ) 9 <br /> COUNTY R JURISDICTION i FACILrTV f <br /> LOCATION CGDE -OPTIONAL CENSUS TRACTa. TIONAL 911PVISOFt-DISTILICT -QP7rDANL <br /> I /0 <br /> ylo <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE iMFcOW=ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(393) FOR001AM <br /> �r <br />