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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> / UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> A ' <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ S CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED BITE <br /> ONE REM 2 INTERIM PERMIT O 6 AMENDED PERMIT ❑ S TEMPORARY SITE CLOSURE .7Z <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCELe(OPTIONAU <br /> in1F s � <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> /Z Into CA 952yv <br /> TO Nq X D CORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY0 OOUNIY-AGENCY' O STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> If avner of UST Is a public agency, DISTRICTS <br /> eenplete,the febunNe:hors,d SuPsI d division,section,or dliw which operuee the UST <br /> TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTORQ ✓ IF INDIAN s OF TANKS AT SITE E.P.A. I.D.a(apNon4 <br /> RESERVATION /f <br /> ❑ 3 FARM (] / PROCESSOR S OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME( $T,FIg/.S�n PHONE JI WITH AREA CO E DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NI TS: NAME(NIST,FIRST) PHONEe WITH AREA C00ENIGHTS: NAME(LAST,FIRST) PHONES WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM/LE � .-,�• ry?� CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ bmbbbka 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> • D. / � D CORPORATION O PARTNERSHIP O COUNTY AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE Y WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> / f <br /> MAILING OR STREET ADDRESS ✓box bkdksN 0 INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> r,>. CORPORATION 0 PARTNEASMP O COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAMESTATE_ ZIP CODE PHONE 0 WITH AREA CODE <br /> G orb 1 4/S2w <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if queslions arise. <br /> TY(TK) HQ 4 4- - <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BECOMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓born InsdkMe O i SELF-INSURED 0 2 GUARANTEE 0 3INSURA14CE 0 A SURETY BOND <br /> O 5 LETTEROFCREDIT 0 6 EXEMPTION D eB 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.� I. III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTHIDAY/YEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY 0 JURISDICTION M FACILITY <br /> 3 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT --OPTIONAL S VI OR-DISTRICT CODE •OPTIONAL <br /> Z-- 23. R70 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IWORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3831 FOR003LI.R7 <br />