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• • rr�5�v...gept <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> �+ 1y f <br /> Cit rp�N`* <br /> COMPLETE THIS FORM FOR EACH FACILTTYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F_j 7 PERMANENTLY CLOSED SI <br /> ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ $ TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DRA 04kACILITY NAME NAME OF OPERATOR <br /> .G aE -�._ <br /> ADDR SS, <br /> + o " NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NA&: STATE ZIP coD SITE PHONE#WITH AREA CODE <br /> CA J <br /> ✓ BOX - <br /> TGINDICATECORPORATION E71INDIVIDUAL [] PARTNERSHIP E] LOCAL-AGENCY COUNTY-AGENCY <br /> DISTRICTS C] STATE-AGENCY �I FEDERAL AGENCY <br /> TYPE OF BUSINESS = t GAS STATION ❑ 2 DISTRIBUTOR L—i ✓ IF INDIAN IN OF TANKS <br /> RESERVATION AT SITE E.P.A. I.D.#(optional} <br /> 0 3 FARM a 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: NAME(LAST,FIRST) 6c/`L) <br /> rt e, 1 <br /> NIGHTS: NAME(LAST,FIRSTI PHONE#WITH AREA CODE N GHTS: NAME(LAST,FI ST) <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED, <br /> NAME , `� CARE OF ADDRESS INFORMATION <br /> MAILINGORSTREETA RESS ✓box bir;d1ate = INDIVIDUAL <br /> [] LOCAL-AGENCY STATE-AGENCY <br /> �} []CORPORATION 0 PARTNERSHIP E] COUNTY-AGENCY <br /> CI NAME �-� —� � --� � � FEOr=RAL-AGENCY <br /> ST ZIP E PHONE�7k WITH AREA CODE <br /> -!ti-1 Z--2--3-4- <br /> Ill. <br /> `2-3`-,fes <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STREETADDRESS ✓ box 1;o indicate INDIVIDUAL E] LOCAL-AGENCY L�j STATE-AGENCY <br /> [� <br /> CITY NAME CORPORATION [E PARTNERSHIP (] COUNTY-AGENCY E] FEDERAL-AGENCY <br /> .STATE ZIP CODE PHONE#WITH AREA CODE <br /> 1V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> box loindicale _� I SELF-INSURED 0 2 GUARANTEE <br /> L 3 INSURANCE 0 4 SURETY BOND <br /> i 5 LETTEROFCREDIT 6 EXEMPTION L-1 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or Il is checked. <br /> CHECK ONE BOX INDICATPNG WHICH ABOVE ADDRESS SHOULD RE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ 1I III,❑ <br /> THIS FORM FfAS SEEN COMPLETFD UNDER PENALTY OF PERJURY,AND TO THE HEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURdSDICTION# FACILITY# <br /> LOCATION CO -OPTIONAi CENSUS TRACT# -OPR I SUPVISOR-DISTRICT CODE -OPTIONAL17' 0009 <br /> f <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 /> FORM A(Iz 91) FELE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> qj�_� FOR0093A-R6 <br /> J <br />