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0 <br /> bogy- e <br /> STATE OF CALIFORNIA a! ...... <br /> c <br /> STATE WATER RESOURCES CONTROL BOARD F Jib <br /> ,o <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYIS[TE <br /> MARK ONLY Ca 1 NEW PERMIT 3 RENEWAL PERMIT y 6 CHANGE OF INFORMATION 7 PERMANENTLY CI;OBff§fTE" <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT E] a TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> r ,•! d ,`�.. � �f',�,/ti1��S' G� C_ <br /> ADDRESS <br /> NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 4,1 _� o� / r 12- -1' - 3 <br /> CITY NAME <br /> STATE ZIP CODE ITE PHONE#WITH AREA CODE <br /> I/ BOX <br /> Ca <br /> TO INDICATE CORPORATION C]INDIVIDUAL PARTNERSHIP [] LOCAL-AGENCY COUNTY-AGENCY` [] STATE-AGENCY'` <br /> DISTRICTS' FEDERAL-AGENCY' <br /> li owner of UST is a public agency,complete the toltowing;name of Supervisor of division,sect on,or oflioe which operates the UST <br /> TYPE OF BUSINESS �'j GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN ;1 OF TANKS AT SITE E.P.A. L D.#(gofiona!) <br /> 3 FARM 0 4 PROCESSOR 5 OTHER <br /> 7RI!!E!�!:!!:::S::�i�illl:I:EllqVATI ONTRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME[LAST,FIRST) <br /> PHONE#WITH AREA CODE <br /> 77SG� <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE <br /> # _ <br /> 11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING 17 1 STREET AQDAESS ✓ box bindicate 0 INDIVIDUAL <br /> � � LOCAL-AGENCY (� STATE-AGENCY <br /> f !'U X 7 �2CORPORATION [] PARTNERSHIP COUNTY-AGENCY <br /> CITY NAME FEDERAL-AGENCY <br /> STATE ZIP CODE PHONE#WITH AREA CODE <br /> 27.-c> <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW <br /> NER <br /> —�— CARE OF ADORE <br /> �y�J f SS INFORMATION <br /> MAILING C�STREET ADDRESS ✓ box to indicate / <br /> 0 INDIVIDUAL LOCAL-AGENCY <br /> ' �'r -CORPORATION = PARTNERSHIP ® COUNTY-AGENCY STATE-AGENCY <br /> CITY NAME 0 FEDERAL-AGENCY <br /> STATES ZIP CCDE #WITH AREA CODE <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - a <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate I I SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 4 SURETYBOND <br /> 0 5 LETTEROFCRLDIT 0 6 EXEMPTION Q W OTHER <br /> VI. LEGAL NOTIFICATION AN ILLING 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 AB VE DDRESS SHO�LD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. IL 0 III. <br /> THIS FORM HAS BEEN COM E ED UNDE f"ENA LTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED S SIGNED) OWNER'S TITLE <br /> DATE MONTHlDAYIYEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTIONF_�_ U # FACILITY <br /> 5]q i <br /> LOCATION CODE -OF7IONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -t7PA0AIAL <br /> THIS FORM MUST BE ACCOMPANIED BYAT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3193) OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN STORAGE TANK REGUL.ATIM <br /> FOR0033A-R7 <br />