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• 'ou <br /> STATE OF CALIFORNIA r <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORD A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE �4c rcm-'- <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑, 2 INTERIM PERMIT ❑ I AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Pacific Bell UE-P-47 <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 4051 NpT,,tnn Road ^?ilson <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> St CA <br /> ✓ BOX CORPORATION INDIVIDUAL I]PARTNERSHIP Q LOCAL-AGENCY [ COUNTY-AGENCY' [] STATE-AGENCY' d FEDERAL4GENCY' <br /> TO INDICATE XN DISTRICTS' <br /> If owner at UST Is a public agency,complete the following:name of Supervisor of division.section,or office which operates the VST <br /> / IF INDIAN TYPE OF BUSINESS F__1 3 FARM TATION E:-] 4 PROCESSOR TRIBUR b OTHER �ORRTFI ER LANDS is OF TANKS AT SITE E.P.A. I.D.at(gotianal) <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE i WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Schneiter , Bob 943-6934 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4t WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Pacific Bell-Permit Desk Louana J . Uribie <br /> MAILING OR STREET ADDRESS ,.a venue ✓ box Io1(&ats 0 INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> P. O. Box 15038 Suite 4 CORPORATION = PARTNERSHIP C]COUNrY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> IC,acramento CA 95531 (916) 972-4006 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER GARS OF ADDRESS INFORMATION <br /> Saire as above (I?) <br /> MAILING OR STREET ADDRESS ✓ box IDindicate INDIVIDUAL © LOCAL-AGENCY Q STATE-AGENCY <br /> CORPORATION O PARTNERSHIP COUNTY-AGENCY 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 b indicate 0 1 SELF-INSURED =2 GUARANTEE 0 5 INSURANCE [__1 4 SURETY BOND <br /> C1 5 LETTEROF CREOIT =6 EXEMPTION = 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.ja] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED 6 SIGNED) OWNER'S TITLE DATE MONTWDAY/YEAR <br /> LOCAL AGENCY USE ONLY Record I .D .�.�231568 <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OP TIO IWIL I CENSUS TRACT it -OPTIONAL SUPVISOR-DISTRICT LODE -OP77ONAL <br /> 01 2380 <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 IMPLEItENTING THE UNDERGROUND STORAGE TANK REGULATM <br /> FOROl133AA7 <br /> FORMA(3193) / <br /> j - c/ <br /> _ 1W <br />