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STATE OF CALIFORNIA ,! <br /> STATE WATER RESOURCES CONTROL BOARD 3 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> \1 <br /> j COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O I NEW PERMIT 0 3 RENEWAL PERMIT 0 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE DEM 71 2 INTERIM PERMIT 4 AMENDED PERMIT - S TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBAO F Il NAME OF OPERATOR <br /> S i C. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> b o or - o o <br /> — ZS <br /> CITY NAME STATEZIP CODE TE PHONE s WITH AREA CODE <br /> CA 9' 7 <br /> Box <br /> T NDICATECORPORATION INDIVIDUAL PARTNERSHIP DISTRICTS'ITS'CY I-1 COUNTY-AGENCY' O STATE-AGENCY• O FEDERAL-AGENCY' <br /> •N owner d UST N a public agenry,wnplpe the lolbwine:narre of Supervmar of oWkbn,eedbn,or oNioe which operates the UST <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR RESV IF INDIAN I <br /> ERVATION <br /> a OF TANKS AT SITE E.P.A I.D.a(apHmelJ <br /> 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> A s X37-5$2 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME ! CAflE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ Dos blriNceM INDIVIDUAL D LOCALAGENCY Q STATE-AGENCY <br /> O, COIAOMTI)N PARTNERSHIP COUWYAWNCY O FEDERAL-AGENCY <br /> CITY N STATE ZIP LADE PHONE A WITH AREA CODE <br /> oZ3 <br /> III. TANK OWNER INFORMATION•(MUST BEC PLETED <br /> NAME OF OWN R CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ box bindam 0INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 0RPMATION PARTNERSHIP O COUNrY-AGENCY Q FEDEML-AGENCY <br /> CITY HyMAE�� STATE ZIPODE' D PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)3212-X9669 if questions arise. <br /> TY(TK) HQ F4]4-]- <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)–IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> but NNkek I SELFINSURED Q 2 GUARANTEE O 3 INSURANCE E=1 4 SURETY BOND <br /> D s LETTEROFCREDIT D 9 EXEMPTION 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'STITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY a JURISDICTION s FACILITY tWzD <br /> 96*� <br /> LOCATION CODE -OPTX?N4f CENSUS TRACTS-OPTIONAL9UPVLROR-DISTRICT CODE -OPTKNWL <br /> z3. 522 �o <br /> THIS F6RM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERmrr 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 /> /j'I� <br /> FORM A(393) q� FORUOf1AA1/f�C'y/ <br />