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STATE OFCALIFORWA .. � <br /> STATE WATER RESOURCES CONTROL BOARD W meg' :a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A Y. a <br /> ` 3: ; COMPLETE THIS FNM FOR EACH FACILITYISITIE `"'•�""�� <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE REM 2 INTERIM PERMIT F__I 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBAO FACILITY NAME NAME OF OPERATOR <br /> c <br /> ADDRESS / NEAREST CROSS STREET PARCEL#(OPI)OW <br /> - L7Gtj l// � f 017' <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA OODE <br /> TO INDICATE.1 BOX <br /> }]CORPORanosi [�j INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY Q COUNTYAGENCY' 0 STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner of UST is a Pubfic agency,complete the following:name of Supervisor of d"lon,section,m office which operates the UST <br /> TYPE OF BUSINESS1 GAS STATION 0 2 DISTRIBUTOR O ✓ IF INDIAN #OF TgNKS AT SITE E.P.A. I.D.#(cplAonag <br /> RESERVATION <br /> 3 FARM = 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-Optimal <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE i WITH AREA CODE <br /> NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME I CARE OF ADDRESS INFORMATION <br /> moi ' T� G• <br /> MAILING OR STREET ADDRESS ✓boa b indicate INDIVIDUAL LOCAL-AGENCY =STATE-AGENCY <br /> f� /� 1 CORPORATION PARTNERSHIP COUNTYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE ,� PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE CO PLETED) <br /> NAME OF OWN R CARE OF ADDRESS INFORMATION <br /> I <br /> MAILING ORSTREET ADDRESS -X box bindicate 0INDIVIDUAL LOCAL-AGENCY l=STATE-AGENCY <br /> /j Qjt' I�'CORPORATKIN O PARTNERSHIP Q COUNTY AGENCY O FEDERAL AGENCY <br /> CnY/NA{ME 9TATEZIP 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) HQ F4-F4--]-� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUSTBECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box loWicale 1�1 SELF-INSURED 1=2 GUARANTEE 3 INSURANCE O 4 SURETY BOND <br /> 5 LETTER OF CREDIT 0 6 EXEMPTION 93 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 /> CHECKONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L O II. IN. <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) OWNERS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#FR III?L2Lm21_.CJ <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPWW <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 REGULATKMIS <br /> FORM A(3'93) FORMM-R] <br />