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STATE OF CAUFORMA D/p,f DOSS Cpl err•', s <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> a UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM A '� <br /> COMPLETE THIS FORM FOR EACHFACILTfY/SITE r.,,,a,,,•' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ a AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DRA OR FACILITYNAME NAME OF OPERATOR <br /> S T 0 aJ <br /> ADDRESS NEAREST CROSS STREET PMICELI(OPrONAU <br /> CITY NAA STATE 21P CODE SITE PHONE i WITH AREA CODE <br /> I/ go C- CA <br /> TOINDCATE O CORPORATION 0 IKWOUAL Q PARTNERSHIP Q LCCAL4GENCY ED COUKIYAGENCY' O STATE-AGENCY' Q FEDERAL-AGENCY' <br /> DISTRICTS' <br /> ' <br /> It caner of UST ie a public agency,conplate the foluwing:nanle of Supmiw M dNYbn,eaction.w office whirls operate,the UST <br /> TYPE OF BUSINESS ❑ i GAS STATION ❑ 2 DISTRIBUTOR O ✓ IF INDIAN a OF TANKS AT SITE E.P.A. I.D.a ImrAj <br /> RESERVATION <br /> ❑ 3 FARM Q a PROCESSOR ❑ 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•apttonal <br /> DAYS: NAME(LAST.FIRST) PHONE•WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE <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 /> NCARE OF ADDRESS INFORMATION <br /> AN <br /> �T /�,20 AI <br /> MAIUUQ OR STREET ADDRESS DOn 4.I DG (�OSGO °°gibi°""' INDIVIDUAL OLOCAL AGENCY OSTATE AGENCY <br /> CORPORATION PARTNERSHIP Q COUNTY.AGENCY 0 FEDERALAGENCY <br /> CITY NAME STATE ZIP CODS P NE a WITH AREA CODE <br /> a- a <br /> III. TANK OWNER INFORMA ON-(MUST BE COMPLETED) <br /> NAME OFCCgqWNER CARE OF ADDRESS INFORMATION <br /> U�Alt dl) <br /> MAILING OR STREET ADDRESS ✓ woirdice, Q INDIVIDUAL O LOCAL AGENCY O STATE AGENCY <br /> Q CORPORATION PARTNERSHIP D COUNTYAGERCY 0 FEDERALAGENCY <br /> CITY NAME STATE LP CODE PHONE a WITH AREA CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ boGlrlfAraM Q I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE o .SURETY BOND <br /> =5 LETTER OF CREW Q a EJIE vnoN Q 9e OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sem 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. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNERS NAME(PRINTED a SIGNED) OWNER'S TITLE DATE MONTWDAYNEAR <br /> LOCAL AGENCY USE ONLY o q O <br /> COUNTY r JURISDICTION 0 FACILITY s <br /> 10101 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT, • nONAL SUPVISOR-DISTRICTC -OPIOCVML <br /> r <br /> TRIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE YFORMATION ONLY.\r <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMP'LEMEHTING THE UNDERGROUND STORAGE TANK REGULATIONS v� <br /> FORM A(3N3) a , <br />