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STATE OF CALIFORNIA i <br /> STATE WATER RESOURCES CONTROL BOARD iW <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FORE H FACILrTY/SITE <br /> MARK ONLY O 3 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION Q 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT O 5 TEMPORARY SITE CLOSURE 53 <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRAAO�R FACILITY NAME NAME OF OPERATOR <br /> Ar- E7 rrae& SPt-fv, A d?vrPN;6 N <br /> ADDRESS NEARESTCRO STREET PARCEL#(OPTIONAL) <br /> z9voS d* S rte/ Sv- <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> ecklb,) CA 95ao,r; <br /> ✓ BOX <br /> TO INDICATE L__j CORPORATION INDIVIDUAL 11 PARTNERSHIP Q LOCAL-AGENCY O COUNTY AGENCY O STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS O 1 GAS STATION Q 2 DISTRIBUTOR O ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> RESERVATION <br /> 3 FARM O 4 PROCESSOR O 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA LADEDAYS: NAME(LAST,FIRST) <br /> "4, T� 209- — o0 <br /> PHONE A WITH AREA r.CN]5 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE I WITH APPA QQnF] <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> C <br /> MAILING OR RESS ST%0T ✓bxblml b 0 INDIVIDUAL D LOCAL-AGENCY O STATE AGENCY <br /> Z S" $/ S O CORPORATION = PARTNERSHIP [71 COUNrY.AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> 5*ckfa9.l C 5zaz <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> r(S <br /> MAILING OR STREET ADDRESS ✓ box bindLab INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> Q CORPORATION O PARTNERSHIP COUNTYAGENCY O FFDERALAGENCY <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 - p z z 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box niMiGle O 1 SELF-INSURED O GUARANTEE 3 INSURANCE D 4 SURETY BONG <br /> D 5 LETTEROFCREDIT I6 EXEMPTION O 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: I. II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PR INTED&S IGNATURE) APPLICANPS TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY x JURISDICTION It FACILITY# <br /> ® I 1 45 &A17 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPV13R-DISTRICT CODE -OPTIONAL <br /> 2 3, 3 XS' c>!f <br /> THIS FORM MUST BE ACCOMPANIED FAT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIG j)NLY. <br /> FORM A(5-91) lAOD33A 5 <br />