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1 0 r,60Ve <br /> STATE OF CALIFORNIA ,! ''� <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION• FORM A :! <br /> COMPLETE THIS FORM FOR EACH FACILIFYISITE `�<�.ae�,' <br /> MARK ONLY O 1 NEW PERMIT O 3 RENEWAL PERMIT5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLO TE_ <br /> ONE REM F__1 2 INTERIM PERMIT Q 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE � 3 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> 0 AORFA ILITYNA E NAMEOFOPERATOR , <br /> G <br /> OD . <br /> ESS Y NEARESTCRO STREET U V PARCEL 0(OFRONAU <br /> CITY NAI STATE 21P CODE SITE ONE#WITH AREA CODE <br /> 'A �7It4- 3s <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL p PARTNERSHIP - O LOCAL-AGENCY COUNTY-AGENCY' STA -AGENCY' <br /> DISTRICTS' FEDERAL-AGENCY' <br /> If owner d UST Is a public agency,complete the lPllovdng:name of Supervreor of dNhbn,section.or oeioe which operalse the UST C#..� <br /> TYPE OF BUSINESS I GAS STATION 2 DISTRIBUTOR O ./ IF INDIAN #OF TANKS ATS E E.P.A. I.D.#(xpHmalJ <br /> RESERVATION �ry <br /> (� 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: VAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 2V 61M65t, aoy `f Lf- 5 / <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) / PHONE#WITH AREA CODE <br /> Il, PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> �o � J k' bt'('S D /O O <br /> MAILING OR STREET ADDRESS ✓ mx0mate 1=1 INDIVIDUAL O LOCAL-AGENCY TATE-AGENCY <br /> O CORPORATION = PARTNERSHIP 0 COUNTYAGENCY FEDEMLAGENCY <br /> iCITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ,4 <br /> MAILING OR STREET ADDRESS '✓ box bindioale INDIVIDUAL OLOCAL-AGENCY STATE AGENCY <br /> O CORPORATION PARTNERSHIP ] COUNTY#GENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP 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 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bimi,ale ED I SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND <br /> L]'5 LETTER OF CREDIT O e 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: 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'SNAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAYIYEAR <br /> LOCAL AGENCY USE ONLY epC_ j <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONM. <br /> ?' <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 WRH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(3'93) • 0 <br /> FOR0033A-R7 <br />