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STATE OF CAUFORMA a <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> NARK ONLY r-1 1 NEW PERMIT Q S RENEWAL PERMIT5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLO <br /> ONE ITEM Q 2 INTERIM PERMIT Q 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME NAME00/FA <br /> ADORE')) NEARESTgRO T EET PARCEL#(OPTIONAO <br /> O\ S• <br /> ll <br /> CITY NAME STATE ZIP O r T O E#WITH AREA CODE <br /> S D CA 10 <br /> ✓ Bo% <br /> ' <br /> TOINOCATE )<CORPORATION INDIVIDUAL O PARTNERSHIP Q LOCAL-AGENCYOCDUNY-AGNCYD STATE-AGENCY• O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> '6 caner of UST Is a public agency,mrrplxe the fdlowep:name of Supervisor d division,section,or office who operates the UST <br /> TYPE OF BUSINESS 0 1 GAS STATION Q 2 DISTRIBUTOR O RESERVATION.1IFIN #OF TANKS AT SITE E.P.A. I.D.#([phonal) <br /> 0 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(UST,FIRST) _ PHON #WITH E DE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> S I o�0 <br /> NIGHTS: NAME T,FIRfiJf PHONE-30 WIT AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME S/} m12:— A 5 FQCiif CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box biimica INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> D CORPORATION (] PARTNERSHIP COUNTYAGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> S tit <br /> MAILING OR 11fREET ADDRESS ✓ box so mil INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> CORPORATION O PARTNERSHIP 0 COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION-UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQITA4 -� <br /> V. PETROLEUM UST FINANCIAL 1Bf ITY-(MUST BE COMPLETED)—IDENTIFY THEMETHOD(S) USED <br /> ✓ bor biMEale Q 1 SELF-INSURED L-1 2 GUARANTEE Q 3 INSURANCE _ O A SURETYBOND <br /> D 5 LETTEROFCREDT I3 6 ExEMPTKIN 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. II.Q III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACLITY# <br /> aq <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRN:T CODE -OWTKJIVAI. <br /> 1 � ©© D <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 /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(393) � ^�`� FQIOWM417 <br />