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N.�w��- 04 :L COW" d4t*E d� Yo 00, r <br /> you. ; o <br /> STATE OF CALIFORNIA �� <br /> STATE WATER RESOURCES CONTROL BOARD s`��, . �� <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ae <br /> C>(,FO,�Y�� <br /> COMPLETE THIS FORM FOR EACH F ILITYISITE <br /> MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATIONO 7 PERMANENTLY CLOSE RE <br /> ONE ITEM O 2 INTERIM PERMIT 0 6 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 /> ADMMI <br /> NEA ST CROSS STRRET� PARCEL%(OPrIONAL) <br /> CITY NAME STATE ZIP CODE SITE PH NE%WITH AREA CODE <br /> $' 1'K CA ao5 <br /> TO INDICATE O CORPORATION INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY COUNTY AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 7 GAS STATION 2 DISTRIBUTOR O ✓ IF INDIAN RESERVATION %OF TANKS AT SITE E.P.A. I.D.%(oplialal) <br /> 3 FARM [_-] 4 PROCESSOR '= 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DA ' NAME(IST.FIRST) , AREA CODE DAYS: NAME(LAST.FIRST) <br /> 0 oePHONE a WITH AREA CODE <br /> NIG TS: NAME(LAST,FIRS HONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM ^ CARE OF ADDRESS INFORMATION <br /> De <br /> MAILING OR STREET ADDRESS ✓ box b Indicate D INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> o 0.2 <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME ^ /a ST ZIP COD) NE%WITH AREA CODE <br /> � n A <br /> I&_3 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) VA )Tr <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box blMkau 0INDIVIDUAL D LOCAL-AGENCY 0 STATE AGENCY <br /> CORPORATION 0 PARTNERSHIP 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)323-9555 if questions arise. <br /> TY(TK) HO 4 4 - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ w binObab 1 SELF-INSURED 0 2 GUARANTEEINSURANCE 0 d SUREN SONO <br /> O 5 LETTER OF CREDIT B EXEMPTION (] 09 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: I.O 11. III.O <br /> T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,ANDTO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTSNAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> LOCAL AGENCY USE ONLY rj a <br /> COU�NTY% JURISDICTION% <br /> LOCATION 4E -OPTIONAL CENSUS TRACT% -OPTIO L SUPVISOR-DISTRICT E -OPTIONAL <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) 2 J � ,— ���'f� FOR00330 <br />