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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A e <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> MARK ONLY EVI NEW PERMIT 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM El 2 INTERIM PERMIT L J 4 AMENDED PERMIT [�] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&AD E -(MUST BE COMPLETED) <br /> DRAORF COILIjY'(J AMENAME OF OPERATOR <br /> r Jho <br /> ADDR S N RESTCROSSSTREET PARCEL#(OPTIONAO <br /> CITU <br /> STATE ZIP D A SITE PHONI WITH AREA CODE <br /> CA G <br /> T NDICATE O CORPORATION E=1 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL-AGENCY O COUNTY-AGENCY O STATE-AGENCY O FEDERAL AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O I GAS STATION 2 DISTRIBUTOR = RV IF INDIAN <br /> #OF T K T SITE E.P.A. I.D.#(optional) <br /> 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) PHONE A WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Ron nheOn <br /> MAILITREET ESS ✓ box bindcal# 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> Y 0 CORPORATION O PARTNERSHIP D COUNTY-AGENCY Q FEDERALAGENCY <br /> CITY A • <br /> STA74E ZIP 1 YIHONE#WI AREA O <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bbbbb# O INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> O CORPORATION O PARTNERSHIP COUNTYAGENCY = FEDERAL-AGENCY <br /> CITYNAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if quesfions arise. <br /> TY(TK) HQ 14 4 -n � <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMP ED)-IDENTIFY THEMETHOD(S) USED <br /> ✓ box bintlicaie (] I SELF-INSURED 0 2AUARAwnEE 0 3 INSURANCE 4 SURETY BOND <br /> l� 5 LETrEROFCREDT EXEMPTION I—J 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: L[—] it.v <br /> III.E] <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# CILITY# <br /> 3'9 L= <br /> LOCATION CODE -0 DONAL 'C PTIONA ISUPVISOR-DISTRICT CODE -OP NAL <br /> 23 • O Z I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A R6 <br /> V <br />