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STATE OF CALIFORNIA <br /> s <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT Eg 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> $ Ad.., Ta gAasA t <br /> ADDRESSF NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> 3 F. a r L. W <br /> CITY NAME STATE ZIP CODE IF SITE PHONE#WITH AREA CODE <br /> 510 <br /> TOINDICATE CVCORPORAnONBox 01 INDIVIDUAL =PARTNERSHIP IE DL CANL-A ENCY COUNTYAGENCY 0 STATE-AGENCY FEDEML-AGENCY <br /> CTS <br /> TYPE OF BUSINESS BKOLI GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(optbnal) <br /> RESERVATION <br /> Q 3 FARM E__] 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I DAYS: NAME(LAST,FIRST) ?Jr <br /> s— <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGH : NAME(LAST,FIRST) <br /> .� o - f - mss- Su ,AAe7f' 09- YS 9 -036 <br /> PHONE#WITH ARE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> enrVN <br /> MAILINGOBSTRDDRESS EETA ✓ box bindicate 0INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY <br /> O, QZ`3 O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY [-I FEDERAL-AGENCY <br /> CITU NAME STATE ZIP CODE <br /> 7J4�7 PHONE#WITH AREA CODE <br /> OAAGOra <br /> /`717 <br /> III. TANKOWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> samAr aig <br /> MAILING OR STREET ADDRESS ✓ wbimkaw F] INDIVIDUAL LOCAL AGENCY STATE AGENCY <br /> Q CORPORATION 0 PARTNERSHIP (]COUNTYAGEWY 0 FEDEPAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 if questions arise. <br /> TY(TK) HQ 4 4 0 0 0 0 <br /> V. PETROLEUM UST FINANCI L RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ OOM bIMkala 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETYBOND <br /> I=5 LETTER OF CREDIT =6 EXEMPTION 0 W 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 hacked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.O II.EK III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PA IN TED B SIGNATURE) APPLICANTS TITLE DATE MONTWDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-D!;CT CODE -OPTIONAL <br /> 2 3 70 3 2 3 /R�/3 9/ G' <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 /> FORM A(5-91) FOROW3A5 <br />