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STATE OFCALIFORNIA � edoao e. <br /> oa <br /> STATE WATER RESOURCES CONTROL BOARD is <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A "�� we <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE o���ep"��a. <br /> MARK ONLY D 1 NEW PERMIT O 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT E:14 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> AD13O©3 —L <br /> T�" NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME 51ATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> CA <br /> ✓ eox <br /> TOINq'ATE Lip <br /> CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY Q COUNTY AGENCY Q STATE-AGENCY FEDEMLAGENCY <br /> A� DISTRICTS <br /> r—OFOUSINESS O 1 GAS STATIO 2 DISTRIBUTOR */ IFVINDIAN #OF TANKS AT SITE E.P.A. I.D.a Inptl l) <br /> 3 FARM 4 PROCESSOR 0 5 OTHER ORRESERATION <br /> TRUST LANDS <br /> EMERGENCY CONTACT P SON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> NIGHTS: NAME(LAST,FIRST) ONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION- MST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓OovblFAbaM INDIVIDUAL LOCA4AGENCY 0 STATEAGENCY <br /> _ 0 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE CO LETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS- ✓ Wx0iMkal# INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME' - STATE ZIP CODE PHONE s WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCO NT NUMBER•Call(916)323-9555 if questions arise. <br /> TY(TK) HQ L4 4 C1� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST B COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓wbirdkaie 1 SELF-INSURED 0 2 GUARANTEE L__1 3 INSURANCE 4 SURETY BOND <br /> I�5 IETTEROFCREDIT 6 EXEMPTION I=W 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.0 II.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3i9 F mT5L/ <br /> LOOATIONDE OPTIONAL CENSUSTRACT* OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM UST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION. FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION <br /> FORM A(1291) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS�� <br /> ^_3 D ' lFOR0033A R <br /> If 6� <br /> J (—/l <br />